Background Checks...A Necessary Tool

Background checks are so important when you are screening Intended Parents and Surrogates. The IP's want to make sure that their surrogate has no DUI's or criminal activity in their past and the Surrogates want to be reassured that their Intended Parents don't have any child molestation or abandonment issues in their past. The form below is a sample. I suggest that you find a professional outfit to run your background checks for you. You can build in the cost into your agency fees.

Sharon LaMothe
Infertility Answers, Inc.
http://infertilityanswers.org/
LaMothe Services, LLC
http://lamotheservices.com/


BACKGROUND CHECK RELEASE FORM

1) Signing this authorizes a background check.

2) You may not be offered entrance into or Surrogacy or Egg Donation Program based on it.

3) You can review the report and dispute errors prior to official turndown.

LAST NAME FIRST MIDDLE NAME SOC.SEC# FULL DATE OF BIRTH ______________ ________ ________ _______ __/__/____

PRESENT Address___________________________
CITY,ST,ZIP_____________________County____________ Years_____

PRIOR Address___________________________CTY,ST,ZIP____________________
County_____________Years_____

List any other counties in which you resided in
the last seven years. DRIVER LIC# _____________STATE:___ Your phone( )__________Cell _______________Home ______________Work

Other names used ____________________________

COLLEGE 1)_______________________City,ST_________________Dates(years) there: ______________DEGREE?________

2)___________________ ______________ ______________ ________

HIGH SCHOOL_____________________City,ST_________________ Dates(years) there: _______________Graduate? _________

DEGREES/LICENSES________________________YEAR EARNED_________

Name then if different ________________________________________

LIST ALL CONVICTIONS INCLUDING TRAFFIC (Indicate “M” for misdemeanor or “F” for felony. ) YR. NATURE OF OFFENSE WHERE(CITY/ST COUNTY) YR. NATURE OF OFFENSE WHERE (CITY,ST,COUNTY) 1)______ ________________ _________________ 2) ______ ________________ _________________ 3)______ ________________ _________________ 4) ______ ________________

_________________ ______________________Use space here for others: NOTE: INABILITY TO IDENTIFY YOUR PRIOR EMPLOYMENT CAN CANCEL OR DELAY PROCESS.


EMPLOYER NAME STREET CITY/ST PHONE NUMBER SUPV’R NAME DATES THERE 1)_______________________________ ________________ _____________________ ( ____)______________ ________________ FROM_______TO______ YOUR POSITION______________________EARNINGS_____________WHY LEFT?________________________CO-WORKER NAME___________________ 2)_______________________________ ________________ _____________________ ( ____)______________ ________________ FROM_______TO______ YOUR POSITION______________________EARNINGS_____________WHY LEFT?________________________CO-WORKER NAME____________________ 3)_______________________________ ________________ _____________________ ( ____)______________ ________________ FROM_______TO_______ YOUR POSITION______________________EARNINGS_____________WHY LEFT?________________________CO-WORKER NAME____________________

*CIRCLE ANY EMPLOYER WE ARE NOT FREE TO CONTACT. PLACE CHECK MARK BY ANY EMPLOYER YOU ARE INELIGIBLE FOR REHIRE.

I hereby authorize this release to ______________. Any information held by any parties regarding my prior employment , criminal, credit, driving, workers compensation and educational history as well as information regarding my general character and reputation can be released. I release any providers of such information from any liability for providing same. I understand the information may be reviewed initially and periodically by______________. I understand that any falsification of my information may make me ineligible for the ____________ program.


Signed__________________________________ Dated_____________

Notary: ____________________________ Stamp: