*This information will be used for background screening purposes only and will not be used as hiring criteria.
APPLICANT DISCLOSURE AND AUTHORIZATION FORM
[IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION]
DISCLOSURE REGARDING BACKGROUND INVESTIGATION
[Employer] (“The Company”) may obtain information about you from a consumer reporting agency for employment purposes.
Thus, you may be the subje
ct of a “consumer report” and/or an “investigative consumer report” which may include information
about your character, general reputation, personal characteristics, and/or mode of living, which can involve personal interviews
with sources such as your neighbors, friends, or associates. These reports may contain information regarding your credit history,
criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or
employment history, worker’s compensation injuries, or other background checks. You have the right, upon written request
made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative
consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report
obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted
by [One Source, The Background Check Company, PO Box 24148 Omaha, NE 68124, 1.800.608.3645] or another outside
organization. The scope of this notice and authorization is all-encompassing, however, allowing [Employer] to obtain from any
outside organization all manners of consumer reports and investigative consumer reports now and throughout the course of your
employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request
disclosure of the nature and scope of any investigative consumer report.
ACKNOWLEDGMENT AND AUTHORIZATION
I acknowledge receipt of the 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 the Company at any time after
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 [One
Source, The Background Check Company, PO Box 24148 Omaha, NE 68124, 1.800.608.3645], another outside
organization acting on behalf of [Employer], and/or [Employer] itself. I agree that a facsimile (“fax”), electronic or photographic
copy of this Authorization shall be as valid as the original.
Last Name _______________________________________ First ______________________________ Middle _____________
Other Names/Alias_______________________________________________________________________________________
Social Security*
# __________________________________ Date of Birth* ________________________________________
Driver’s License # __________________________________ State of Driver’s License _______________________________
Present Address ________________________________________________ Phone Number__________________________
City/State/Zip___________________________________________________________________________________________
All Previous Addresses in the Last Seven Years________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Signature**: _______________________________________________________ Date: ______________________________
New York applicants or employees only: You have the right to inspect and receive a copy of any investigative
consumer report requested by [Employer] by contacting the consumer reporting agency identified above directly.
California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING
BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to
receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the
Company whenever you have a right to receive such a copy under California law.
□
Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a
consumer re
ort if one is obtained b
the Com
an
. □
