Western Omelette Restaurant (Background Check Authorization)

  I, (Your Name Will Be Populated Here) hereby authorize: 

Western Omelette LLC (the “Company”) of 16 S. Walnut St., Colorado Springs, Colorado 80905, and/or its agents to make investigation of my background, references, character, past employment, consumer reports, education, and criminal history record information which may be in any state or local files, including 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. A telephone facsimile (fax) or xerographic copy of this consent shall be considered as valid as the original consent.


I hereby consent to the Company’s verification of all the information I have provided on my application form. I also agree to execute as a condition of employment or a condition of continued employment any additional written authorization necessary for the Company to obtain access to and copies of records pertaining to this information. I also hereby authorize the Company’s access to any medical histories or records pertaining to me (and any other individuals who due to my employment may be covered by any Company medical or other insurance program). With regard to the foregoing disclosures, I hereby agree to release any person, company, or other entity from any and all causes of action that otherwise might arise from supplying the Company with information it may request pursuant to this release. I understand that any false answers or statements, or misrepresentations by omission, made by me on this application or any related document, will be sufficient for rejection of my application or for my immediate discharge should such falsifications or misrepresentations be discovered after I am employed.


I understand and agree this is a legal representation of my signature.

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