I, (name of applicant), hereby allow ABC Company the right to contact and investigate my former and current employers, and all other pertinent parties, including, but not limited to educational institutions where I enrolled, to fully investigate my background.

I understand that as part of the interview process, since I am applying for the position of (specify), ABC Company requires all applicants to disclose pertinent data concerning previous work history, police and military records, and educational activities.

The purpose and procedures used in this investigation have been fully described to me and I completely understand the reasons and potential uses of such investigations.  I authorize ABC Company to use any and all information acquired to make decisions regarding my employment, which may be disclosed to third parties.

I understand and agree that if any material facts are discovered which differ from those facts stated by me on my employment application, at my interview, or at any time prior to my commencing employment at ABC Company (if I am offered a position with ABC Company), I will not be offered the job.  Furthermore, I understand and agree that if material facts are later discovered which are inconsistent with or differ from facts I furnished before taking the job, I will be disciplined, including immediate discharge without warning.

The cost of this investigation will be paid by ABC Company.  Nonetheless, I hereby indemnify, release and forever discharge and hold ABC Company and its subsidiaries and affiliated companies, agents and employees, as well as all third parties supplying such information, harmless from any and all claims, demands, judgments and legal fees arising out of or in connection with this investigation, the results, or any lawful use of the results or disclosure thereto.

Signature of Applicant

Printed Name of Applicant

Social Security Number:

Date:

Name of Witness: