Employment Background Authorization | Right Path Behavior Health Services

Form I.D.*

Name

First Middle Last

Please list all other names used:

Social Security Number

Sex

Date of birth

Race

Address

Current Address City State / Province / Region ZIP / Postal Code

Years at Residence

Drivers License Number

State Issued

State / Province / Region

Previous Address

Current Address City State / Province / Region ZIP / Postal Code

Years at Residence

Accurate Information & Background Authorization Acknowledgement

I state that the information above is accurate to the best of my knowledge. I also understand that the information about by background may contain negative information about my character and style of living. This release any liability against the company or its against agents. The authorization may be used in copy form.

Name typed below will serve as signature, legally binding this agreement*

First Last

Today's Date*