Business Name*
Enter your full name
Telephone*
Telephone
Date*
Date
Return E-mail Address*
Enter a valid email
Name of Person Making Request*
I hereby release all information pertaining to my criminal, credit, military and work history to Loss Prevention Group. I am aware that all of the above references, as well as my credit report may be reviewed to determine my suitability for employment. I also understand that Loss Prevention Group may perform a background check on me at any time.*
By Typing your name you indicate agreement with the statement.
Have you ever been convicted of a crime?*YesNo
A YES answer will not necessarily disqualify you for employment. If yes, please provide details and location below:*
Driver's Lic #
Driver's Lic State Issued
Applicant Last Name*
Applicant Maiden Name/Alias
Applicant First Name*
Applicant Middle Name
No Middle Name
Applicant DOB*
Applicant Social Security Number*
Applicant E-mail Address*
Current Address*
Current City*
Current State*
Current Zip*
Previous Address
Previous City
Previous State
Previous Zip
States and counties lived in over the previous 7 years:
All data provided is intended solely for the customer who initially receives such data from the provided. The provider cannot guaranty or warrant the accuracy, correctness, or completeness of the data. The provider delivers all data to customers on an “as is” “as available” basis without any express or implied warranty, guaranty, or representation of any kind concerning the data itself, its merchantability, or its fitness for a particular purpose or function. Neither the provider nor any of their affiliates shall be liable for any damages of whatever kind may result from the customer’s reliance on (or use of) the data provided, even if the provider, or any of their affiliates has been alerted to the possibility of such damages. By accessing any such data, the customer acknowledges and agrees that the customer has not relied on anything that may be inconsistent with the Legal Statement. I understand that LPG, acting as the loss preventions department for the company that I am seeking employment with, completes and provides criminal background check information to said company for final review for employment purposes.*I Agree
For a downloadable PDF form to fill out and fax to us, please click HERE to download the PDF.
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