Revision 07/26/17 www.VerifiedFirst.com
DO NOT STAPLE
I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND
INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify
that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports”
and/or “investigative consumer reports” by (“Employer”) at any time aer receipt of
this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation,
any law enforcement agency, administrator, state or federal agency, institution, school or university (public or
private), information service bureau, employer, or insurance company to furnish any and all background information
requested by Verified First, 1550 South Tech Lane, Suite 200, Meridian, Idaho 83642; Tel. # 1-888-670-9564;
www.VerifiedFirst.com and/or Employer. I agree that a facsimile (“fax”), electronic or photographic copy of this
Authorization shall be as valid as the original.
New York applicants only: Upon request, you will be informed whether or not a consumer report
was requested by the Employer, and if such report was requested, informed of the name and address
of the consumer reporting agency that furnished the report. You have the right to inspect and receive
a copy of any investigative consumer report requested by the Employer by contacting the consumer
reporting agency identified above directly. By signing below, you acknowledge receipt of Article 23-A
of the New York Correction Law.
New York City applicants only: You acknowledge and authorize the Employer to provide any notices
required by federal, state or local law to you at the address(es) and/or email address(es) you provided
to the Employer.
Washington State applicants only: You also have the right to request from the consumer reporting
agency a wrien summary of your rights and remedies under the Washington Fair Credit Reporting Act.
Minnesota and Oklahoma applicants only: Please check this box if you would like to receive a copy
of a consumer report if one is obtained by the Employer.
Last Name First Name Middle Name
check box if no middle name
Social Security Number* ###-##-####
Date of Birth*
month/date/year Email Address
required
Driver’s License Number Issuing State*
Former Names/Aliases
separate aliases with comma
CURRENT ADDRESS FORMER EMPLOYER
Street Apt/Unit Company City, State
City State Zip Position Dates of Employment
Applicant Signature Date
PLEASE COMPLETE ALL FIELDS BELOW
*This information will be used for background screening purposes only and will not be used as hiring criteria.
ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK
click to sign
signature
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