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Residential Screening Request
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Community Name
*
First Name
*
Middle Name
*
Last Name
*
Address
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City
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State
Zip Code
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SSN / SIN
DOB
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Home Phone
*
Mobile Phone
*
Email
*
Have you ever been arrested before?
*
--- Select Choice ---
Yes
No
Disclosure / Authorization
DISCLOSURE
AmeriCheckUSA may request one or more consumer reports or investigative consumer reports about you for employment or residential purposes. These reports may include information on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which may be used as a factor in making an employment or residential related decision about you. Such information may include credit reports, criminal history, civil records, etc. or personal interviews with your current or prior employers, neighbors, friends, or associates, or with others who may have knowledge concerning any such items of information.
Authorization
By signing below, I agree that I have read and understand the foregoing Disclosure and hereby authorize AmeriCheckUSA to obtain consumer reports or investigative consumer reports about me for employment or residential purposes. I further authorize AmeriCheckUSA to share the information with any person involved in the employment or residential decision about me. This agreement will not be valid after 90 days of date signed, and you also agree that a fax or photocopy of this authorization with your signature be accepted with the same authority as the original.
READ, ACKNOWLEDGED AND AUTHORIZED
*
Name (One Person Per Form)
Signature
*
Clear Signature
Signature (One Person Per Form)
Date Signed
*
Government Issued ID (Driver's License, Passport, etc.)
Home Last Date
Upload Government Issued ID (Required)
*
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