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Background Check Form

The document appears to be a job application form that requests personal and employment information from applicants. It requests information such as name, contact details, education history, employment history, character references, additional questions about health, criminal history and bankruptcy. It also includes an authorization letter for the employer to conduct background checks and verify the information provided. The form must be completed truthfully and fully, as incomplete or untruthful responses may delay or refuse the application.

Uploaded by

JF Dan
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
352 views

Background Check Form

The document appears to be a job application form that requests personal and employment information from applicants. It requests information such as name, contact details, education history, employment history, character references, additional questions about health, criminal history and bankruptcy. It also includes an authorization letter for the employer to conduct background checks and verify the information provided. The form must be completed truthfully and fully, as incomplete or untruthful responses may delay or refuse the application.

Uploaded by

JF Dan
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 4

Instructions: The applicant must complete this form. All questions must be answered completely and truthfully.

Failure to provide
complete and truthful information may result in the refusal or delay of your application. Please print clearly.

PERSONAL INFORMATION
Last Name: Civil Status:

First Name: Sex:

Middle Name: E-mail Address:

Former Name (if applicable): Landline:

Date of Birth: Mobile Number:

SSS Number: TIN Number:

Current Address:

Permanent Address:

EDUCATIONAL BACKGROUND HIGH SCHOOL COLLEGE / UNIVERSITY

Name of Institute:

Address / Location:

Dates of Attendance:
(MM/DD/YYYY) to (MM/DD/YYYY)
Graduate?  Yes  No | If yes, specify date below: Graduate?  Yes  No | If yes, specify date below:
Date of Graduation:

Course / Qualification:

EMPLOYMENT HISTORY (Start from most recent employer)

Company Name | Address Position Title & Employment Dates Employment


Reason for Leaving
Contact Detail ID Number (MM/DD/YYYY) Status

Page 1 of 4

Prepared by Hiring Basix – A Division of Quaerito Qualitas Inc.


CHARACTER REFERENCES
Preferred Contact
Name Relationship Company / Position Contact Details
Time

Page 2 of 4

Prepared by Hiring Basix – A Division of Quaerito Qualitas Inc.


ADDITIONAL INFORMATION

Have you undergone any operation or surgery?


1
If yes, kindly specify.

Have you been diagnosed with any illness or medical


2 condition?
If yes, kindly specify.

Have you ever been issued any disciplinary action (whether


written warning, suspension, termination from previous
3
employers)
If yes, kindly specify.

Has there been any criminal charges filed against you?


4
If yes, kindly specify.

Have you ever been arrested for or convicted of a


5
criminal offence? If yes, please provide details.

Have you ever been declared bankrupt or had a bankruptcy


6
petition made against you? If yes, please provide details.

Have you been involved in any civil judgments, as a Plaintiff


7
or Defendant? If yes, please provide details.

Have you ever been refused entry to any country?


8
If yes, please provide details.

Are you currently engaged in any other business either as a


proprietor, partner director, trustee, employee, and agent or
9
otherwise?
If yes, please provide details.

Kindly explain why your Outside Business Interests would or


10 would not result in any form of conflict with your proposed
role.

Page 3 of 4

Prepared by Hiring Basix – A Division of Quaerito Qualitas Inc.


LETTER OF AUTHORISATION

I hereby grant authorisation the employer and any person or organisation acting on its behalf to verify information presented in my
application form and to procure a background screening report for that purpose. I understand that such a report may contain
information about my background, character and personal reputation. I further understand and agree that, in the event of my
employment, a background screening report may be procured in connection with subsequent employment decisions.

Upon my written request, I will be advised of the name and address of each employment reporting agency from which an
employment report or investigative report may have been obtained. I also voluntarily authorise ______________, and a vendor on its
behalf, to perform reference checks of my employment (with the exception of my current employer, unless I have authorised such
contact or commenced employment with Employer) and such other checks and inquiries are necessary in order to verify information
provided by me in my employment application. I hereby release from liability all persons or entities requesting or supplying such
information. Moreover, I understand that my employment with the Firm may be terminated with immediate effect should any
information provided herein be proven untrue.

Full Name: _____________________________

Date of Birth: _____________________________

Identity #: _____________________________
(valid ID)

Date: _____________________________

Signature: _____________________________

Page 4 of 4

Prepared by Hiring Basix – A Division of Quaerito Qualitas Inc.

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