Candidate Printed Name Social Security # Candidate Signature Date

I hereby authorize the City of Dallas to obtain information regarding my current and prior employment from Equifax (The Work Number) for employment purposes only. I understand that if no results are yielded from the City’s contracted employment verification service, a designated City of Dallas hiring authority may contact my current or past employers directly to obtain the necessary information.

Candidate Printed Name Social Security # Candidate Signature Date

MANUAL VERIFICATION
Company Name / Location (City, State) / Company Phone Number / Contact Person / Dates Verified
Start Date – End Date / Title Verified / Date Verification Completed
FOR INTERNAL USE ONLY
Signature of authorized person completing manual verification / Date / Verified / Not Verified

This authorization form should be uploaded to the Equifax system. If no results are returned from Equifax, this form should be used by an authorized City of Dallas representative to manually verify employment history for the consenting applicant noted above.

PER-FRM-596 Rev 1 7/19/2016