[ + ]   Instructions

Please complete the Background Check Release Form by providing all information requested.

You should gather all information needed for this form first and take less than 8 hours from logging in to fill and Submit this release. You'll need ID info, Exact Employment Info, Exact Education Info, References and Gaps Listed.

Please fill in this form, read the Fair Credit Reporting Rights information and Press the SUBMIT button.

Any documents, proof, or other information you are submitting can be attached to this form in the appropriate section. Please ONLY Attach PDF files or small sized (under 1 MB) non-PDF files.

Expand and collapse the sections below by clicking on the section header.

[ + ]   Personal Information
Legal First Name:
Legal Middle Name:
Legal Last Name:
Suffix (ex: Jr., Sr., if applicable):
Gender:
Your Email Address:
Your Telephone Number:
If applicable, Please list your Maiden name:
Have you have used another name (Y/N):
If you marked Yes to "Alias", Please list the names in the following fields:
SSN (US only):
Canada SIN:
Date of Birth (format MM/DD/YYYY):
Drivers License Country:

Drivers License State/Province:

Drivers License #:

[ + ]   Fill this Section if you Lived or Worked outside of the USA in the past 7 years
Nationality (if Non-USA):

Passport Issuing Country (if Non-USA):

Passport Number (if Non-USA):
PAN or Other National Citizen ID (non-USA):
If you hold a non-USA issued Passport, list your father's name:
If you hold a South American Passport, list your Mother's maiden name:

Passport/ID Scan:


[ + ]   Residential Address History

List Your Current Address:


Country:

Street: Apt Num/Suite/Other:
City: State/Province:

Zip/Postal Code:
Date Range (format MM/YYYY): to Present

List All Previous Addresses Lived Within the Past 7 Years:


2. Country:

Street: Apt Num/Suite/Other:
City: State/Province:

Zip/Postal Code:
Date Range (format MM/YYYY): to


3. Country:

Street: Apt Num/Suite/Other:
City: State/Province:

Zip/Postal Code:
Date Range (format MM/YYYY): to

[ + ]   ADD RESIDENTIAL ADDRESS
4. Country:

Street: Apt Num/Suite/Other:
City: State/Province:

Zip/Postal Code:
Date Range (format MM/YYYY): to
[ + ]   ADD RESIDENTIAL ADDRESS
5. Country:

Street: Apt Num/Suite/Other:
City: State/Province:

Zip/Postal Code:
Date Range (format MM/YYYY): to
[ + ]   ADD RESIDENTIAL ADDRESS
6. Country:

Street: Apt Num/Suite/Other:
City: State/Province:

Zip/Postal Code:
Date Range (format MM/YYYY): to
[ + ]   ADD RESIDENTIAL ADDRESS
7. Country:

Street: Apt Num/Suite/Other:
City: State/Province:

Zip/Postal Code:
Date Range (format MM/YYYY): to
[ + ]   ADD RESIDENTIAL ADDRESS
8. Country:

Street: Apt Num/Suite/Other:
City: State/Province:

Zip/Postal Code:
Date Range (format MM/YYYY): to
[ + ]   FCRA Summary / Notice to CA and NY Residents

A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT


NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW


NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO NEW YORK LAW

[ + ]   Authorization

In consideration of being considered by MARTIN UNITED METHODIST CHURCH or its customer for a position, I hereby authorize MARTIN UNITED METHODIST CHURCH and its agents, including but not limited to Cluso Investigation LLC, to perform the required investigative inquiries into my personal background, covering the counties and states where I have been employed or resided for the past seven years or longer as permitted by law. MARTIN UNITED METHODIST CHURCH and its agents, including but not limited to Cluso Investigation LLC, have my authorization to develop information regarding my work habits, skills, and general character from employers, personal references, schools, or institutions, including but not limited to state workers’ compensation histories, and/or obtain information from law enforcement, judicial, and military authorities concerning my conduct or criminal history (including but not limited to traffic violations), and to share such information with MARTIN UNITED METHODIST CHURCH’s customer if applicable.

I authorize any current or former employer, school, or other organization or entity identified herein to release any information about me to Cluso Investigation LLC or MARTIN UNITED METHODIST CHURCH, including but not limited to personnel records and any records concerning drug or alcohol testing or any refusal to consent to testing. A facsimile, photocopy or other copy of this authorization may be accepted by anyone as though it were an original.

I consent to the release of my Motor Vehicle Records (MVR) to MARTIN UNITED METHODIST CHURCH and its agents under the provisions of the Federal Driver’s Privacy and Protection Act and in accordance with any other applicable local, state or federal laws.

I understand that this Background Check Release Form is not to be deemed a request to obtain or release any information where such request or release is not permitted by applicable law. I further understand that the results of any pre-employment investigation, if found to be unsatisfactory according to the policy(ies) of MARTIN UNITED METHODIST CHURCH or a prospective employer if different, may be cause for denial of employment.

I hereby certify that all information furnished by me herein is true, complete, and accurate to the best of my knowledge. I hereby release MARTIN UNITED METHODIST CHURCH, Cluso Investigation LLC, their respective affiliates and customers, and all officers, directors, agents, employees, and representatives of any of the foregoing, of and from any claims or liabilities of any kind resulting from such background investigations or the provision or use of information derived through such investigations, including but not limited to the denial of employment.


Please read your FCRA Rights Information below before electronically signing this release and pressing the Submit button. Any questions should be directed to ops@cluso.com with "Online Release Question" in the Subject line.

Maine, Massachusetts, and New Jersey residents: You have the right to inspect and promptly receive a copy of any investigative consumer report requested by MARTIN UNITED METHODIST CHURCH by contacting Cluso Investigation directly. All contact information is available at the top of this form.

Minnesota residents: You have the right, upon written request to Cluso Investigation, to receive a complete and accurate disclosure of the nature and scope of any consumer report. Cluso Investigation must make this disclosure within five days of receipt of your request or of MARTIN UNITED METHODIST CHURCH's request for the report, whichever is later.

New York residents: You have the right to request whether MARTIN UNITED METHODIST CHURCH requested a consumer report and, if so, MARTIN UNITED METHODIST CHURCH will give you the name and address of the report's provider if other than Cluso Investigation.

California, Oklahoma, or Minnesota residents:
Checkmark here if you want a copy of your final background check report:
If you checkmarked to receive a copy, list your email address if you prefer to receive your copy via email (otherwise you will receive by regular mail):

Washington residents: MARTIN UNITED METHODIST CHURCH will provide the disclosure described above concerning its procurement of an investigative consumer report either five days after receiving your request or after requesting the investigative consumer report, whichever is later. You have the right to ask MARTIN UNITED METHODIST CHURCH to provide you with a summary of your rights under the Washington Fair Credit Reporting Act.

Checkmark you understand your FCRA Rights (REQUIRED):

I acknowledge receipt of the NOTICE REGARDING BACKGROUND CHECKS PURSUANT TO CALIFORNIA LAW and certify that I have read and understand this document (REQUIRED):

I acknowledge receipt of the NOTICE REGARDING BACKGROUND CHECKS PURSUANT TO NEW YORK LAW and certify that I have read and understand this document (REQUIRED):

Your Text Signature:

Draw your signature by holding the left mouse button and dragging or by using your touchscreen.
Clear

and Print Name:

Date (format MM/DD/YYYY):

Print Release

Note: If you get an error message after submission, please hit the back button, correct and submit again.
The most likely cause of errors are file attachments. Try reducing the size of each attachment to under 1MB.
If you are unable to submit the form for any reason you can always print and email this release with your attachments to ops@cluso.com with subject "Online Release Form with Attachments."
Be sure to include your name and the company you are filling the release for.
If you are still experiencing issues, please make note of the error message and contact us at ops@cluso.com with subject "Online Release Error."