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Authorization Form

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dartstockbroking
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38 views1 page

Authorization Form

Uploaded by

dartstockbroking
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Authorization for Release of Information for Employment Purpose

Background Screening Disclosure

I hereby authorize Proquest Consultancy Services Pvt Ltd, Hyderabad and its designated
agents and representatives to conduct a comprehensive review of my background through
a consumer report and/or an investigative consumer report to be generated for
employment, promotion, reassignment or retention as an employee. I understand that the
scope of the consumer report/investigative consumer report may include, but is not limited
to, the following areas: names and dates of previous/current employment, work
experience, worker’s compensation claims, criminal history records (from local, state,
federal, international and other law enforcement agencies’ records), sexual offender’s lists,
wants and warrants records, motor vehicle records, military records, educational
verification, license verification, credit history, civil cases, OIG/GSA, OFAC/patriots act, any
sanction lists, FBI finger printing and drug testing.

Authorization and Release

I, Prachi Patil authorize the complete release of these records or data pertaining to me
which an individual, company, firm, corporation, or public agency may have. I authorize
the full release of the information described above, without any reservation, throughout
any duration of my employment at Dartstock Broking Pvt. Ltd. for 3 years. I hereby release
PROQUEST, and its agents, officials, representatives, or assigned agencies, including
officers, employees, or related personnel both individually and collectively, from any and
all liability for damages of whatever kind, which may at any time, result to me, my heirs,
family or associates because of compliance with this authorization for release of
information. I certify that all information provided below and on my resume is correct to
the best of my knowledge. Any false statements provided in this form and my resume will
be considered just cause for the termination of employment at any time. This authorization
and consent shall be valid in original, fax, or copy form.

The following information is required by law enforcement agencies and other entities for
identification purposes when checking records. It is confidential and will not be used for
any other purpose.

_______________Prachi Patil _________________________________________________________


Applicant’s Name (First) Middle Name Surname

______Prachi _____________________Sanjeev______________ Patil

___24__/_01_/2024_______

Signature

Date
__05______/ 10________/_ 1996_____
Date of Birth (This will not affect hiring decision)

_____________________________ _____Maharashtra_______
Driver License Number State

_______ 704/B Blue Bell, Hiranandani Estate, Thane West, Maharashtra.


_________________________________________________________________
Current Address

(______)___9130115533_________________
Phone

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