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Graham/Sheehan Security Services, Inc.
45 Wiley Hill Road
Londonderry, NH 03053
Tel: 603-437-6900
Fax: 603-437-6918

INFORMATION VERIFICATION RELEASE
* Please make sure all information supplied is legible *

Employee/Applicant Name ___________________________________________________
Other names used: * ________________________________________________________
DOB: ________________ POB ________________ SSN: ________________

Current and Prior Addresses: (please cover at least last 7 years of residence)
____________________________________________________________________________________
(Street No and Name) (City) (State) (Zip) (Dates Resided) *
____________________________________________________________________________________
Previous (Street No and Name) (City) (State) (Zip) (Dates Resided) *
____________________________________________________________________________________
Previous (Street No and Name) (City) (State) (Zip) (Dates Resided) *
____________________________________________________________________________________
Previous (Street No and Name) (City) (State) (Zip) (Dates Resided) *
____________________________________________________________________________________
Previous (Street No and Name) (City) (State) (Zip) (Dates Resided) *

Current Driver’s License Number & State: ________________
Previous Driver’s License Number & State: ________________

AUTHORIZATION RELEASE

I, _______________________________, born at ______________ on ______________ having
(name) (Citv State Country) (Date)
filed an application for employment in the position of ______________ at ______________ hereby
(Title) (Company/Household)
apply for a background report and consent to have an investigation made as to my character, professional reputation and fitness for the position I have applied for and such other information as may be received. all of which will be reported to __________________.
(Company/Household)

I hereby agree to give any further information which may be required concerning my past record I understand that the contents of my background report are private.

I also authorize and request every person, firm, company, corporation, governmental agency, law enforcement agency, court, association or institution having control of any documents, records or other information pertaining to me, to furnish to Graham/Sheehan Security Services, Inc any such information, including documents, records, and files, whether formal or informal, pending or closed or any other pertinent data; and to permit Graham/Sheehan Security Services, Inc or any of its agents or representatives to inspect and make copies of such documents. records, files or other information.

I hereby release, discharge and exonerate Graham/Sheehan Security Services. Inc , its agents and representatives and any person so furnishing information from any and all liability of every nature and kind arising out of the furnishing or inspection of such documents, records, files and other information or the investigation made by Graham/Sheehan Security Services, Inc.

I have read the foregoing document and I have answered all questions with respect to my application for a background report fully and frankly. The answers are complete and true of my own knowledge and I affix my signature hereto freely and voluntarily.

____________________________________________________________________________________
(Signature of Applicant) (Date) (Witness Signature)

*Licensed* *Bonded* *Insured*