AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES
Background Screening Disclosure
I hereby authorize Bank Simpanan Nasional and Verity Intelligence Sdn Bhd and its designated agents and representatives to
conduct a comprehensive review of my background through a consumer report and/or a background check report to be generated
for employment, promotion, reassignment or retention as an employee. I understand that the scope of the report/background
check report may include, but is not limited to, the following areas: names, dates and internal disciplinary records of
previous/current employment, work experience, workers compensation/claims, criminal history records (from local, state, federal,
international and other law enforcement agencies’ records), wants and warrants records, motor vehicle records, educational
verification, license verification, business interest and directorship, financial checks with Credit Reporting Agencies and Bank
Negara Malaysia Central Credit Reference Information System or CCRIS record, civil cases, any sanction lists, and drug testing.
Authorization and Release
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 authorize the full release of the information
described above, without any reservation. I hereby release Bank Simpanan Nasional and Verity Intelligence Sdn Bhd, 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, my heirs, family or
associates because of compliance with this authorization for release form. I certify that all information provided below and at any
other times are correct to the best of my knowledge. Any false statements provided in this form and any other documents
provided will be considered just cause for the termination of employment at any time. This authorization and consent shall be valid
in original, fax, or copy form.
The following information is required by law enforcement agencies and other entities for identification purposes when checking
records. It is confidential and will not be used for any other purpose.
Applicant’s Name: ________________________________________ (______)____________________ Mobile Phone
ID /Passport Number:_____________________________________ _______/________/_______ (Month/Day/Year)
Date of Birth (This will not affect hiring decision)
Current Address: ___________________________________________________________________________________________
_________________________________________________________________________________________________________
____________________________
Applicant’s Signature
Date:
COMPANY REFEREE INFORMATION (please make sure you have informed your Referees below on your job application)
Referee #1: Ex-Supervisor Referee #2: Ex-Supervisor Referee #3: Ex-Supervisor
Name: Name: Name:
Designation: Designation: Designation:
Company Name: Company Name: Company Name:
Tel No: Tel No: Tel No:
Email Address: Email Address: Email Address:
Can we contact your Current Employer? (please tick one)
Now ____ OR
Later ____ (we will only conduct this check upon your hiring organization’s instructions to Verity)
Important Note:
We will be contacting the HR Department of your previous companies and possibly the reporting supervisors as
provided by HR or the Referees you have provided. We will also contact the HR Department of your current
company, as instructed above. If you have any concerns, kindly raise this for discussion during the interview.
