Background Screening Information Form

Personal Information

First Name: Cameron Middle Name: Tyler Last Name: Hay

Maiden Name/Other Names Used: Date Last Used:

Email Address: Timebomb081909@gamil.com

Social Security Number: 436874748 Date of Birth: 07/26 /1993 Sex: X Male ☐ Female

Drivers License Number: 009796006 State: Louisiana

All addresses for the last SEVEN years: (List addresses beginning with the most recent)

1. 130 wallace circle minden louisiana 71055 2019- 2022

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2. 7800 youree drive apt 712 shreveport louisiana 71105 2015-2019

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5-Year Employment History: (List all employers, beginning with most recent employer)

Employment Dates (Month/Year From: To: August 2021- December 2021

Company Name: Underdawgs

Phone: (318)413-5761

Address: 605 Main Street City: Minden

 State: Zip: 71055

Job Title(s): Head bartender

Supervisor Name: Rick and Claudine Adams

Reason for
Leaving: Salary Dispute

Employment Dates (Month/Year From: To: April 2009 to July 2019

Company Name: Carrabba's Italian Grill

Phone: (318)798-6504

Address: 1706 East 70th Street City: Shreveport

State:louisiana Zip:71105

Job Title(s): Head bartender Supervisor Name Michelle Cornellius

Reason for
Leaving: Covid 19 layoffs

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Education History:
School Name and Location From To GPA/ Major Type of Date Degree Obtained
(mo/yr) (mo/yr) Class Degree or to be Obtained
Standing
 1. Benton High School 08/11 01/12 3.6 HiSET February 09/2022

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