CADENCE PETROLEUM GROUP
AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize Cadence Petroleum Group and its designated agents and
representatives to conduct a comprehensive review of my background through a
consumer report and/or an investigative consumer report to be generated for employment,
promotion, reassignment or retention as an employee. I understand that the scope of the
consumer report/investigative consumer report may include, but is not limited to the
following areas: verification of social security number, current and previous residences,
employment history including all personnel files, education, character references, credit
history and reports, criminal history records from any criminal justice agency in any or
all federal, state county jurisdictions, motor vehicle records to include traffic citations and
registration and any other public records.
I authorize the complete release of these records or data pertaining to me which an
individual, company, firm, corporation, or public agency may have. I understand that I
must provide my date of birth to adequately complete said screening, and acknowledge
that my date of birth will not affect any hiring decisions. I hereby authorize and request
any present or former employer, school, police department, financial institution or other
persons having personal knowledge of me, to furnish bearer with any and all information
in their possession regarding me in connection with an application for employment. This
authorization and consent shall be valid in original, fax, or copy form.
I hereby release Cadence Petroleum Group; and its agents, officials, representatives, or
assigned agencies, including officers, employees, or related personnel both individually
and collectively, from any and all liability for damages of whatever kind, which may at
any time, result to me because of compliance with this authorization. You may contact
me as indicated below; I understand that a copy of this authorization may be given to me
at any time, provided I request it in writing. Information on this application and results of
the background investigation will be maintained in confidence in accordance with
company hiring practices.
Name: _________________________________________________________________
First Middle (full name) Last Maiden
Signature: ___________________________________Date:_______________________
See Other Side
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CADENCE PETROLEUM GROUP
Print All Former Names Used: (Maiden or AKA)
_____________________________________________________________________
Last First Middle
_____________________________________________________________________
Last First Middle
_____________________________________________________________________
Last First Middle
Current Street Address: ____________________________________________________
City: ____________________________________ State: ______ Zip: _______
Print Residences in the previous 7 years (City, State & Zip Code)
City: ____________________________ City: ____________________________
State: ___________ Zip: ____________ State: ___________ Zip: ____________
City: ____________________________ City: ____________________________
State: ___________ Zip: ____________ State: ___________ Zip: ____________
City: ____________________________ City: ____________________________
State: ___________ Zip: ____________ State: ___________ Zip: ____________
SSN: ________-______-_________
Month of Birth: _____ Day of Birth: ______ Year of Birth: ________
Drivers License Number: __________________________ Issuing State: _____________
May we contact your current employer? Yes No
Have you been convicted of a felony, misdemeanor, or traffic infraction? Yes No
If yes, explain, please include when and where:
________________________________________________________________________
________________________________________________________________________
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Home Phone Number: ___________________ Cell Phone Number: _________________
