Welcome to Biolase Technology, Inc.

* I am aware that BioLase Technology, Inc. has requested DataCheck to perform a background check in connection with my employment application. Any information obtained, as a result of such an investigation is confidential and will be provided only to BioLase Technology, Inc. I have voluntarily provided the information listed below and in my employment application and understand that false, misleading, or omitted information may be grounds for termination now or in the future. I am fully aware of the purpose for this background check, and therefore request that people, companies, references, current or former employers, schools, government agencies, any and all credit reporting agencies and others contacted provide information to DataCheck. I release all of those mentioned above, from any liability whatsoever for this purpose.

DataCheck is a professional pre-employment background investigation firm performing background checks as its normal course of business. DataCheck may make an investigative report in which information is obtained through business associates, financial sources, credit reporting agencies, educational institutions, law enforcement agencies, or other third parties with whom I may be acquainted. This information may include inquiries as to my character, general reputation, work habits, personal characteristics, driving records or credit standing. If requested by BioLase Technology, Inc., I hereby authorize DataCheck to obtain a copy of my credit report from any or all credit reporting agencies it deems necessary in order to perform this background check and make available this report to BioLase Technology, Inc.

Further, a comprehensive criminal search may be performed, and I voluntarily release from any liability whatsoever, all parties, persons, companies, institutions, government agencies, courts, police departments, or others for furnishing such information. I hereby release my date and year of birth for the purpose of the criminal investigation. I have the right to request additional disclosures regarding the nature and scope of this investigation.

I have read and understand that I am releasing all of those listed above from any liability whatsoever for the purpose of obtaining or furnishing background information on my personal history. I further acknowledge and agree to indemnify and hold DataCheck and BioLase Technology, Inc. harmless from and against any and all claims, demands, or liabilities, including court costs and attorneys’ fees, arising from or in connection with any pre-employment background check, including the ordering of credit reports, the researching of criminal history, employment history, education, and driving records. I understand that by signing this document I am agreeing and giving permission to perform this background check. I authorize that a copy of this authorization may be considered as valid as an original.

If you are currently employed, may we contact your current employer? Yes No *

First Name:	*
M.I.:
Last Name:	*
Current Home Address:	*
Address (cont.):
City:	*
State:	*
Zip/Postal Code:	*
Maiden Name:
Other Names you have been known by:
Social Security Number:	- - *
Name as shown on your Social Security Card:	*
Driver's License Number:	*
Driver's License State:	*
Driver's License Expiration:	* mm/dd/yyyy
Name as shown on your Driver's License:	*

Your date and year of birth is required for the Criminal search. You may provide your date and year of birth on this form, or if you would like, DataCheck will contact you for this information.
Date of Birth:	* mm/dd/yyyy
Daytime Phone:	*

Other counties where you have lived in the past ten years:
County: State:
County: State:
County: State:

* I am aware that consumer and motor vehicle reports may be obtained as part of Biolase Technology, Inc.’s evaluation of my job application and/or employment. The reports may be procured by BioLase Technology, Inc., or it’s insurance company representative(s) and may include personal information obtained from state motor vehicle departments, my driving record, or an assessment of my insurability for the insurance program. * By checking this box, I hereby provide my authorization for BioLase Technology, Inc. or their insurance company representative(s) to procure such information and reports, as well as additional reports about me from time-to-time as deemed appropriate, to evaluate my insurability or for other permissible purposes.