Background Disclosure Application

I hereby authorize Jump In Northwest and/or it's agents to make an independent investigation of my background references, character, past employment, education, criminal, or police records. This includes those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my Application and/or obtaining other information, which may be material to my qualifications for employment now, and if applicable, during the tenure of my employment with Jump In Northwest.

I release Jump In Northwest and/or it's agent and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims, or lawsuits in regards to the information obtained from any and all of the above referenced sources used.

The following is my true and complete legal name, and all information is true and correct to the best of my knowledge.

Fields highlighted in 'red' are required


Last Name	First Name	Middle Name

Other Last Name or Maiden Name	Other Last Name or Maiden Name


Present Street Address		How long?

City, State, Zip Code


Previous Street Address		How long?

Previous City, State, Zip Code

MM DD YY	- -
Date of Birth	Social Security Number	Drivers License Number

		MM DD YY
Signature		Signed Date