8/14/2019 Background Consent Form

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CONSENT FORM TO REQUEST INFORMATION FOR A CRIMINAL BACKGROUNDCHECK

I understand that the Servpro

of ___________ will conduct a criminal history backgroundcheck as part of the procedure for processing my application for employment. I understandthat Servpro of ___________ will conduct an investigation that verifies my social securitynumber and includes obtaining information regarding my past employment and criminabackground. I understand the criminal history background check will include my countiesof residence to search for criminal records. I also understand that before I am deniedemployment based on information obtained in the report, I will receive explanation and acopy of my rights under the Fair Credit Reporting Act.

I understand that if I disagree with the accuracy of any information in the report, I mustnotify the Servpro of _________ Owner within three (3) business days of receipt of the

report. If I notify Human Resources within this time, I will have a reasonable opportunity toaddress the information contained in the criminal history background check report. understand that the information contained in the criminal history background check will beavailable to those persons involved in making employment decisions or performing thebackground investigation, and that this information will be used for the purposes omaking employment decisions.

Caution Read Before Signing

I hereby consent to the criminal history background check as described above andauthorize the Servpro of __________ obtain reports concerning my background as stated

above. I hereby release Servpro

of __________, its officers, agents and employees from anyand all liability related to the Servpro of __________ using my criminal backgroundinformation to make employment decisions.

Signature of Applicant: ___________________________________Date_______________

Print Full Name____________________________________________________ __(First) (Middle) (Last)

Social Security #: ________________________________________________________

Date of Birth: ___________________________________________________________

Drivers License #: _______________________________________________________

State of License: _________________________________________________________

Servpro of Northeast Georgia 3847 Cherokee Ford Janice Swilley: 770-54-1004Servpro of South Georgia Gainesville, GA 30506 Email: jcswilley@charter.net

Servpro of Western South Carolina Office: 770-532-6293 Rob Wilkerson: 770-539-2761www.servpro.com Fax: 770-532-7777 Email: servpro2214@gmail.com

Independently Owned & Operated

Like it never even happened

Fire & Water Cleanup & Restoration

8/14/2019 Background Consent Form

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Position Applied for _______________________________________________________

The Servpro of ___________ is authorized to conduct a criminal history background checkon job applicants pursuant to Code Section 50-27-12.1et. Seq. of the Georgia StateLegislature Code. Providing your social security number and date of birth are necessary to

perform these investigations and will only be used with your consent for the purposesdescribed above. Date of Birth information is obtained for identification purposes only andwill not be used as a basis for making employment decisions.

Servpro of Northeast Georgia 3847 Cherokee Ford Janice Swilley: 770-54-1004Servpro of South Georgia Gainesville, GA 30506 Email: jcswilley@charter.net

Servpro of Western South Carolina Office: 770-532-6293 Rob Wilkerson: 770-539-2761www.servpro.com Fax: 770-532-7777 Email: servpro2214@gmail.com

Independently Owned & Operated