*This information will be used for background screening purposes only and will not be used as hiring criteria.
[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.
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__________________________
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
The federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the files of
every consumer reporting agency (CRA). You can find the complete text of the FCRA, 15 U.S.C. 1681-1681u, at the Federal Trade
Commissions web site (http://www.ftc.gov). The FCRA gives you specific rights, as outlined below. You may have additional rights
under the state law. You may contact a state or local consumer protection agency or a state attorney general to learn those rights.
1. You must be told if information in your file has been used against you. Anyone who uses information from a CRA to take action
against you--such as denying an application for credit, insurance or employment must tell you and give you the name, address, and
phone number of the CRA that provided the consumer report.
2. You can find out what is in your file. At your request, a CRA must give you the information in your file and a list of everyone who
has requested it recently. There is no charge for the report if a person has taken action against you because of information supplied by
the CRA, if you request the report within 60 days of receiving notice of the action. You are also entitled to one free report every
twelve months upon request if you certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on
welfare, or (3) your report is inaccurate due to fraud. Otherwise, a CRA may charge you up to eight dollars.
3. You can dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurate information, the CRA
must investigate the items (usually within 30 days) by presenting to its information source all relevant evidence you submit, unless
your dispute is frivolous. The source must review your evidence and report its findings to the CRA. (The source also must advise
national CRAs--to which it has provided the data, of any error.) The CRA must give you a written report of the investigation and a
copy of your report if the investigation results in any change. If the CRAs investigation does not resolve the dispute, you may add a
brief statement to your file. The CRA must normally include a summary of your statement in future reports. If an item is deleted or
dispute statement is filed, you may ask that anyone who has recently received your report be notified of the change.
4. Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate or unverified information from its
files, usually within 30 days after you dispute it. However, the CRA is not required to remove accurate data from your file unless it is
outdated (as described below) or cannot be verified. If your dispute results in any change to your report, the CRA cannot reinsert into
your file a disputed item unless the information source verifies its accuracy and completeness. In addition, the CRA must give you a
written notice telling you it has reinserted the item. The notice must include the name, address and phone number of the information
5. You can dispute inaccurate items with the source of the information. If you tell anyone--such as a creditor who reports to the CRA--
that you dispute an item, they may not then report the information to a CRA without including a notice of your dispute. In addition,
once you*ve notified the source of the error in writing, it may not continue to report the information if it is, in fact, an error.
6. Outdated information may not be reported. In most cases, a CRA may not report negative information that is more than seven years
old; ten years for bankruptcies.
7. Access to your file is limited. A CRA may provide information about you only to people with a need recognized by the FCRA,
usually to consider an application with a creditor, insurer, employer, landlord, or other business.
8. Your consent is required for reports that are provided to employers or reports that contain medical information. A CRA may not
give out information about you to your employer, or prospective employer, without your written consent. A CRA may not report
medical information about you to creditors, insurers, or employers without your permission.
ou may choose to exclude your name from CRA lists for unsolicited credit and insurance offers. Creditors and insurers may use
file information as the basis for sending you unsolicited offers of credit or insurance. Such offers must include a toll-free phone
number for you to call if you want your name and address removed from future lists. If you call, you must be kept off the lists for two
years. If you request, complete and return the CRA form provided for this purpose, you must be taken off the lists indefinitely.
10. You may seek damages from violators. If a CRA, a user or (in some cases) a provider of CRA data, violates the FCRA, you may
sue them in state or federal court.
The FCRA gives several different federal agencies authority to enforce the FCRA. For questions or concerns regarding:
CRAs, creditors and others not listed below, please contact:
Federal Trade Commission
Bureau of Consumer Protection-FCRA,
Washington, DC 20580 (202) 326-3761
National banks, federal branches/agencies of foreign banks, please contact:
Office of the Controller of the Currency
Compliance Management, Mail Stop 6-6
Washington, DC 20219 (800) 613-6743
Federal Reserve System member banks, please contact:
Federal Reserve Board
Division of Consumer & Community Affairs
Washington, DC 20551 (202) 452-3693
Savings associations and federally chartered savings banks, please contact:
Office of Thrift Supervision
Consumer Programs
Washington, DC 20552
(800) 842-6929
Federal credit unions, please contact:
National Credit Union Administration
775 Duke Street
Alexandria, VA 22314
(703) 518-6360
Federal Deposit Insurance Corporation
Division of Compliance & Consumer Affairs
Washington, DC 20429
(800) 934-FDIC
Air, surface or rail common carriers regulated by former Civil Aeronautics Board of Interstate Commerce Commission, please
Department of Transportation
Office of Financial Management
Washington, DC 20590
(202) 366-1306
Activities subject to the Packers and Stockyards Act, 1921, please contact:
Department of Agriculture
Office of Deputy Administrator-GIPSA
Washington, DC 20250
(202) 720-7051