Notification & Authorization

to Release Criminal Information for Employment Purposes

Notification: The position for which I am being considered requires me to consent to a criminal background check as a condition of employment. This check includes the following: Criminal history reference searches for felony and misdemeanor convictions at the county and federal levels of every jurisdiction where I currently reside or where I have resided during the past 7 years; and sex offender registry searches at the county and federal levels in every jurisdiction where I currently reside or where I have resided.

Authorization: I hereby authorize The Collective to conduct the criminal background check described above. In connection with this, I also authorize the use of law enforcement agencies and/or private background check organizations to assist The Collective in collecting this information. Validity CIA research has been secured as a third party vendor (consumer reporting agency) to assist The Collective in collecting and verifying information.

I also am aware that records of arrests on pending charges and/or convictions are not an absolute bar to employment. Such information will be used to determine whether the results of the background check reasonably bear on my trustworthiness or my ability to perform the duties of my position in a manner which is safe for The Collective ambassadors and members.

Position(s) Applied for

Name

First Name

Last Name

Other names you have used in the past 7 years

Current Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Previous Address (most recent)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Addresses in the 7 years prior to completing this authorization

Phone

(###)

###

####

Alternate Phone Number

(###)

###

####

Date of Birth

YYYY

Gender

Female

Male

EIN / Social Security Number

Driver's License Number / State

Have you ever been convicted of a criminal *offense or have any pending criminal *charges against you?

*This refers only to felonies and misdemeanors; you do not need to include non-criminal traffic violations or municipal ordinance violations.

Yes (provide detail below)

Conviction or Pending Details

Digital Signature

First Name

Last Name

Recognition of Digital Signature

I agree that my electronic signature is the legally binding equivalent to my handwritten signature, that it has the same validity and meaning as my handwritten signature, and that I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding. By signing the Agreement, I consent to be legally bound by the Agreement's terms and conditions.

I AGREE

Date

YYYY