Contractor Background Verification Certificate

"*" indicates required fields

Full Name and Address of Contract Worker

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Do NOT provide Year of Birth

Hidden

Date of Hire by Contractor (Company)

Date*

Contractor (Company) hereby certifies:

Check One:*

A background check has been conducted in accordance with the requirements stipulated by BASF Corporation (“BASF”) on the named Contractor above and the results are satisfactory.

A background check has been conducted in accordance with the requirements stipulated by BASF Corporation (“BASF”) on the named Contractor above and the following potential problems were found:

(Please describe in the space provided below the potential problems found)

These potential problems have been resolved as follows:

(Please describe in the space provided below the resolutions)

Name of Contractor (Company)*

By:*

Title:*

Date*

Forms

After-Hours Class Request Form
Baytown Credit Card Authorization
Beaumont Credit Card Authorization
Contractor Background Verification Certificate
Electronic Billing Forms
ExxonMobil Bottle Watch and MX-6 Monitor Training Prerequisite Form
Frontline Supervisor Specialized Training Request Form
ISTC Client Information Forms
Job/PO Number Required Form
Minimum/After-Hours Rigging Verification (09MORIGV) Authorization
On-Site Request Form
Specialized On-Site Request Form
Specialized Training Request Form
Subscriber Credit Application