PERMISSION FORM TO RUN A BACKGROUND SCREENING 

Upon signing this form, you authorize MoneyGram Payment Systems, Inc and firms that collect information on its behalf to obtain information from government sources and elsewhere, including your criminal history and similar information, in order to investigate and evaluate this inquiry. The undersigned further agrees that neither MoneyGram Payment Systems, Inc nor anyone who has furnished MoneyGram Payment Systems, Inc any information concerning the Business or the undersigned shall be responsible for any loss or damage the Business or undersigned may claim as resulting from verification, receipt, exchange, or obtaining criminal history or other business and/or personal information. 

Applicant’s Name:		_______________________________________________

Other Names Used:		_______________________________________________

Applicant’s Address:		_______________________________________________

City / State / Zip:		_______________________________________________

Social Security Number:	_______________________________________________

Driver’s License Number and State: 	____________________________________

Name as appears on Driver’s License:	____________________________________

Date of Birth: 	________________________

Applicant’s Signature:	________________________________________________