Confidential: Request for Verification

TO: From: Pre-employ.com, Inc.

PO Box 491570
Redding CA 96049
Phone: 800-300-1821 FAX: 888-999-3839
Physical Address: 3655 Meadowview Drive
Redding, CA 96002

For the purpose of preparing an authorized background report by Pre-employ.com for my

prospective employer, and only for that specific purpose, and subject to all laws protecting my
informational and individual privacy, I, the undersigned, hereby authorize and request the
following to disclose to Pre-employ.com the information needed to compile the report: my past or
present employers; learning institutions, including colleges and universities; law enforcement and
all other federal, state and local agencies, commissions and departments; federal, state and local
courts; the military; credit bureaus; testing facilities; and motor vehicle records agencies. By
signing below, I acknowledge the information that can be disclosed to Pre-employ.com, if and only
as allowed by law, includes, but is not limited to, information concerning my employment and
earnings history, education, motor vehicle history, credit history, criminal history, military service,
and professional credentials and licenses. I authorize the Photostat or electronic copy of this
Request for Verification to be considered as effective and valid as the original.
Name: Last First Middle

Date of Birth Social Security Number: (Last 4 Digits:)

(MM/DD):

/ /XXXX XXX-XX-

Case Number:

By entering your electronic signature below, you are (a) agreeing to use an electronic signature to demonstrate your
authorization, and (b) acknowledging your understanding that it is as legally binding as an ink signature.
Authorization

Signature Date

The information contained in this transmission is confidential information intended for the use of the individual(s)
named above. If the reader of this message is not the intended recipient, you are hereby notified that dissemination,
distribution, or copying of this communication is strictly prohibited. If you received this transmission in error, please
immediately notify me by telephone to arrange for transmission correction.
The Pre-employ.com Family of Companies
Pre-employ.com , Mybackgroundcheck.com, and I-9Compliance.com
PO Box 491570, Redding, CA 96049 - Phone: 800-300-1821 FAX: 888-999-3839
Signed Release Form, Version 2.3