Residential Background Check

Community Name

First Name

Middle Name

Last Name

Address

City

State

Zip Code

SSN / SIN

DOB

Home Phone

Mobile Phone

Email

Have you ever been arrested before?

Employment Verification

Company Name

Supervisor/HR Contact Name

Contact Phone Number

Employment Start Date

Employment End Date

Job Title/Position

Salary

Have you caused any problems?

Are you eligible for rehire?

Landlord Verification

Landlord Name

Landlord Phone Number

Lease Start Date

Lease End Date (if applicable)

Phone You? you

Monthly Rent Amount

Have you caused any problems?

Have you made any late payments?

Do you have pets? (If so, specify Type / Breed / Weight)

Character Verification

Person’s Name

Person’s Phone Number

Relationship to You?

Length of Time Known Each Other?

Have you ever had any problems with this person?

Do they consider you a responsible person?

Do they consider you are of good moral character?

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.)

Upload Government Issued ID (Required)

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