Business Name

Date

Your Email (required)

Phone Number

Person Making Request

Your Name (required)
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.

Have you ever been convicted of a crime? YesNo If yes, please provide details and location below:
*A YES answer will not necessarily disqualify you for employment.

Last Name (required)

Maiden Name (required)

Alias Name (required)

First Name (required)

Middle Name (required)

Date of Birth (required)

Your Email (required)

Social Security Number (required)

Email Address