Background Check Information

The information requested below is collected solely for the purpose of aiding GENEVA in running a background check in connection with your application for employment. GENEVA is requesting that you provide this information to assist in conducting a thorough background check. For residents of, or for jobs located in Utah, please do NOT provide your date of birth, social security number, or driver's license number until instructed to do so by the company.
Name*
First Middle Last
Gender*
Date of Birth*
MM slash DD slash YYYY
Ethnicity*
Phone Number*
Social Security Number*
Driver's License Number*
State Issuing Driver's License*
Enter Any Other Names Used (Including Maiden Names):
First Middle Last
First Middle Last
First Middle Last
Addresses Within the Past Seven Years
Present Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email Address*
Do you have a prior street address?
Prior Street Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you have another prior street address?
Prior Street Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you have another prior street address?
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you have another prior street address?
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Authorization for Background Checks
After carefully reading this Background Check Disclosure and Authorization form, I authorize GENEVA to order my background report, including investigative consumer reports. I understand that GENEVA may rely on this authorization to order additional background reports, including investigative consumer reports, during my employment without asking me for my authorization again as allowed by law. I also authorize the following agencies and entities to disclose to the Background Check Company and its agents all information about or concerning me, including but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state, and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; if applicable, worker's compensation injuries; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. Workers' compensation information will only be requested in compliance with federal Americans with Disabilities Act and/or any other applicable federal, state or local laws and only after a conditional job offer is made. The information that can be disclosed to the Background Check Company and its agents includes, but is not limited to, information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses and substance abuse testing. I agree that GENEVA may rely on this authorization to order background reports, including investigative consumer reports, from companies other than the Background Check Company without asking me for my authorization again as allowed by law. I also agree that a copy of this form is valid like the signed original. I certify that all of the personal information I provided is true and correct.
Name*
First Middle Last
If you live or work in California, Minnesota, or Oklahoma: Check this box if you would like a free copy of your background check report:
Signature*
Date*
MM slash DD slash YYYY