Pre-Employment Background Check Form

Personal Information

Full Name * Address (Street) * City * State * ZIP Code * Phone Number * Date of Birth (MM/DD/YYYY) * Social Security Number * Email Address * Driver’s License Number Driver’s License State Previous Names/Aliases

Criminal History

Have you been convicted of a felony? *

Details (dates, charges, outcomes)

Employment History (Last 2 Jobs)

Most Recent Job

Employer Dates (MM/YYYY - MM/YYYY) Supervisor Name & Contact

Previous Job

Employer Dates (MM/YYYY - MM/YYYY) Supervisor Name & Contact

Professional References

Reference 1

Name Phone/Email

Reference 2

Name Phone/Email