BACKGROUND CHECK AUTHORIZATION FORM FOR CANDIDATES

ELECTRICAL ENGINEERING ASSOCIATE 22-00088

JOB TITLE APPLYING FOR: ________________________________________ REQ #, if any: _____________________

Nelson Flores
CANDIDATE’S NAME: _____________________________________________ PHONE #: ________________________ 831-915-7202
OTHER NAMES USED
N/A
(Include Maiden Name): _____________________________________________________________________________

SCHOOL INFORMATION
(Information is needed for job that requires a bachelor’s degree from an accredited four-year college or university.)

California State University, Los Angeles

SCHOOL NAME: ____________________________________________ COMPLETION DATE: ___________________ 5/2021
5151 State Univeristy Dr Los Angeles, CA
SCHOOL ADDRESS: _______________________________________________________________________________

M.S.
DEGREE(S): ____________________________ Electrical Engineering
MAJOR(S): _______________________________________________

JOB INFORMATION
(Information is needed for job(s) from the last 24 months.)

Grid-Scape
CURRENT OR MOST RECENT EMPLOYER: ____________________________________________________________
Junior Engineer
JOB TITLE: _______________________________________________________________________________________

EMPLOYMENT DATES: 9/2021

FROM: _____________________________ Present
TO: _________________________________
Gaurav Kumar
SUPERVISOR’S NAME: _____________________________________ 707-267-8728
PHONE #: ____________________________

California State University, Los Angeles

PREVIOUS EMPLOYER: ____________________________________________________________________________
Student Research Assistant
JOB TITLE: _______________________________________________________________________________________

EMPLOYMENT DATES: 5/2019

FROM: _____________________________ 5/2021
TO: _________________________________
Dr. Masood Shahverdi
SUPERVISOR’S NAME: _____________________________________ 626-283-9352
PHONE #: ____________________________

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AUTHORIZATION FOR THE RELEASE OF CONFIDENTIAL INFORMATION

Nelson Flores
I, _________________________________, hereby grant the City of Los Angeles permission to contact my current and
previous employers to review my personnel records for the purpose of reviewing my work history. I also release the City of
Los Angeles, my current and previous employers from liability for divulging information in records or sharing the judgment
of a supervisor who has direct knowledge of my work ethics, performance, and experience.

This authorization is valid for 90 days from the date signed below.

CANDIDATE’S SIGNATURE: __________________________________________ DATE: ________________________ 2/11/2020

Personnel Department - Revised: 09/2019 1 1

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