AmericanChecked Inc.
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Rev 11/09/16
In connection with my application for employment/licensure (including contract or volunteer services) or
application to rent a dwelling with ___________________________________, I understand consumer reports
will be requested by you (“Company”). These reports may include, as allowed by law, the following types of
information, as applicable: names and dates of previous employers, reason for termination of employment, work
experience, reasons for termination of tenancy, former landlords, education, accidents, licensure, credit, etc. I
further understand that such reports may contain public record information such as, but not limited to: my driving
record, workers’ compensation claims, judgments, bankruptcy proceedings, evictions, criminal records, etc., from
federal, state, and other agencies that maintain such records.
In addition, investigative consumer reports (gathered from personal interviews, as applicable, with former
employers or landlords, past or current neighbors and associates of mine, etc.) to gather information regarding
my work or tenant performance, character, general reputation and personal characteristics, and mode of living
(lifestyle) may be obtained.
If I am hired/licensed, I understand that my employer can use this disclosure and authorization to continue to
obtain such consumer reports throughout my employment/licensure, contract period or volunteer service.
I hereby authorize procurement of consumer report(s) and investigative consumer report(s) by
Company. If hired (or contracted), this authorization shall remain on file and shall serve as ongoing
authorization for Company to procure such reports at any time during my employment/licensure,
contract or volunteer period. I authorize without reservation, any person, business or agency contacted
by the consumer reporting agency to furnish the above-mentioned information.
This authorization is conditioned upon the following representations of my rights:
I understand that I have the right to make a request to the Consumer Reporting Agency: AmericanChecked Inc.,
4870 South Lewis Avenue, Suite 120, Tulsa, OK 74105; telephone: 800-975-9876 (“Agency”) upon proper
identification, to obtain copies of any reports furnished to Company by the Agency and to request the nature and
substance of all information in its files on me at the time of my request, including the sources of information,
and the Agency, on Company’s behalf, will provide a complete and accurate disclosure of the nature and scope
of the investigation covered by any investigative consumer report(s). The Agency will also disclose the recipients
of any such reports on me which the Agency has previously furnished within the two year period for employment
requests, and one year for other purposes preceding my request (California three years). I hereby consent to
Company obtaining the above information from the Agency. I understand that I can dispute, at any time, any
information that is inaccurate in any type of report with the Agency. I may view the Agency’s privacy policy at
their website:
I understand that if the Company is located in California, Minnesota or Oklahoma, that I have the right to request
a copy of any report the Company receives on me at the time the report is provided to the Company. By checking
the following box, I request a copy of all such reports be sent to me. Check here:
AmericanChecked Inc.
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Rev 11/09/16
As a California applicant, I understand that I have the right under Section 1786.22 of the California Civil Code to
contact the Agency during reasonable hours (9:00 a.m. to 5:00 p.m. (CST) Monday through Friday) to obtain all
information in Agency’s file for my review. I may obtain such information as follows: 1) In person at the Agency’s
offices, which address is listed above. I can have someone accompany me to the Agency’s offices. Agency
may require this third party to present reasonable identification. I may be required at the time of such visit to
sign an authorization for the Agency to disclose to or discuss Agency’s information with this third party; 2) By
certified mail, if I have previously provided identification in a written request that my file be sent to me or to a
third party identified by me; 3) By telephone, if I have previously provided proper identification in writing to
Agency; and 4) Agency has trained personnel to explain any information in my file to me and if the file contains
any information that is coded, such will be explained to me.
I understand that if I am applying for employment in New York, that I have the right to receive a copy of Article
23-A of the New York Correction Law ____________(initial if this applies).
I understand that if the report is provided to an employer in the State of Washington, that I can contact the
following office for more information regarding my rights under Washington State Law in regard to these reports:
State of Washington Attorney General, Consumer Protection Division, 800 5
Ave, Ste. 2000, Seattle,
Washington 98104-3188, (206) 464-7744.
In connection with my application for employment/licensure (including contract or volunteer services) or
application to rent a dwelling, I direct the following regarding my current employer: (please check one). Yes, my
current employer may be contacted ________ / No, my current employer cannot be contacted _________
I understand that I have rights under the Fair Credit Reporting Act, and I acknowledge receipt of the Summary
of Rights _____________ (initials).
First Name _______________________ Middle Name/MI ________________ Last Name __________________
Signature ________________________________________________________________________________________
Date ________________________
For identification purposes:
Address _______________________________________________________________________________
Social Security No. ___________________________ Date of Birth ______________________________________
Driver License No. ____________________________ State of Issue _____________________________________
click to sign
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Para información en español, visite o escribe a la
Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
A Summary of Your Rights Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and
privacy of information in the files of consumer reporting agencies. There are many types of
consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies
that sell information about check writing histories, medical records, and rental history records).
Here is a summary of your major rights under FCRA. For more information, including
information about additional rights, go to or write
to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
You must be told if information in your file has been used against you. Anyone who
uses a credit report or another type of consumer report to deny your application for credit,
insurance, or employment – or to take another adverse action against you must tell you,
and must give you the name, address, and phone number of the agency that provided the
You have the right to know what is in your file. You may request and obtain all the
information about you in the files of a consumer reporting agency (your “file
disclosure”). You will be required to provide proper identification, which may include
your Social Security number. In many cases, the disclosure will be free. You are entitled
to a free file disclosure if:
o a person has taken adverse action against you because of information in your
credit report;
o you are the victim of identity theft and place a fraud alert in your file;
o your file contains inaccurate information as a result of fraud;
o you are on public assistance;
o you are unemployed but expect to apply for employment within 60 days.
In addition, all consumers are entitled to one free disclosure every 12 months upon
request from each nationwide credit bureau and from nationwide specialty consumer
reporting agencies. See for additional
You have the right to ask for a credit score. Credit scores are numerical summaries of
your credit-worthiness based on information from credit bureaus. You may request a
credit score from consumer reporting agencies that create scores or distribute scores used
in residential real property loans, but you will have to pay for it. In some mortgage
transactions, you will receive credit score information for free from the mortgage lender.
You have the right to dispute incomplete or inaccurate information. If you identify
information in your file that is incomplete or inaccurate, and report it to the consumer
reporting agency, the agency must investigate unless your dispute is frivolous. See for an explanation of dispute procedures.
Consumer reporting agencies must correct or delete inaccurate, incomplete, or
unverifiable information. Inaccurate, incomplete, or unverifiable information must be
removed or corrected, usually within 30 days. However, a consumer reporting agency
may continue to report information it has verified as accurate.
Consumer reporting agencies may not report outdated negative information. In
most cases, a consumer reporting agency may not report negative information that is
more than seven years old, or bankruptcies that are more than 10 years old.
Access to your file is limited. A consumer reporting agency may provide information
about you only to people with a valid need – usually to consider an application with a
creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a
valid need for access.
You must give your consent for reports to be provided to employers. A consumer
reporting agency may not give out information about you to your employer, or a potential
employer, without your written consent given to the employer. Written consent generally
is not required in the trucking industry. For more information, go to
You may limit “prescreened” offers of credit and insurance you get based on
information in your credit report. Unsolicited “prescreened” offers for credit and
insurance must include a toll-free phone number you can call if you choose to remove
your name and address form the lists these offers are based on. You may opt out with the
nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).
The following FCRA right applies with respect to nationwide consumer reporting
You have a right to place a “security freezeon your credit report, which will
prohibit a consumer reporting agency from releasing information in your credit
report without your express authorization. The security freeze is designed to prevent
credit, loans, and services from being approved in your name without your consent.
However, you should be aware that using a security freeze to take control over who gets
access to the personal and financial information in your credit report may delay, interfere
with, or prohibit the timely approval of any subsequent request or application you make
regarding a new loan, credit, mortgage, or any other account involving the extension of
As an alternative to a security freeze, you have the right to place an initial or extended
fraud alert on your credit file at no cost. An initial fraud alert is a 1-year alert that is
placed on a consumer’s credit file. Upon seeing a fraud alert display on a consumer’s
credit file, a business is required to take steps to verify the consumer’s identity before
extending new credit. If you are a victim of identity theft, you are entitled to an extended
fraud alert, which is a fraud alert lasting 7 years.
A security freeze does not apply to a person or entity, or its affiliates, or collection
agencies acting on behalf of the person or entity, with which you have an existing
account that requests information in your credit report for the purposes of reviewing or
collecting the account. Reviewing the account includes activities related to account
maintenance, monitoring, credit line increases, and account upgrades and enhancements.
You may seek damages from violators. If a consumer reporting agency, or, in some
cases, a user of consumer reports or a furnisher of information to a consumer reporting
agency violates the FCRA, you may be able to sue in state or federal court.
Identity theft victims and active duty military personnel have additional rights. For
more information, visit
States may enforce the FCRA, and many states have their own consumer reporting laws.
In some cases, you may have more rights under state law. For more information, contact
your state or local consumer protection agency or your state Attorney General. For
information about your federal rights, contact:
1.a. Banks, savings associations, and credit unions with total
assets of over $10 billion and their affiliates
b. Such affiliates that are not banks, savings associations, or
credit unions also should list, in addition to the CFPB:
a. Consumer Financial Protection Bureau
1700 G Street, N.W.
Washington, DC 20552
b. Federal Trade Commission
Consumer Response Center
600 Pennsylvania Avenue, N.W.
Washington, DC 20580
(877) 382-4357
2. To the extent not included in item 1 above:
a. National banks, federal savings associations, and federal
branches and federal agencies of foreign banks
b. State member banks, branches and agencies of foreign banks
(other than federal branches, federal agencies, and Insured State
Branches of Foreign Banks), commercial lending companies
owned or controlled by foreign banks, and organizations
operating under section 25 or 25A of the Federal Reserve Act.
c. Nonmember Insured Banks, Insured State Branches of
Foreign Banks, and insured state savings associations
d. Federal Credit Unions
a. Office of the Comptroller of the Currency
Customer Assistance Group
1301 McKinney Street, Suite 3450
Houston, TX 77010-9050
b. Federal Reserve Consumer Help Center
P.O. Box 1200
Minneapolis, MN 55480
c. FDIC Consumer Response Center
1100 Walnut Street, Box #11
Kansas City, MO 64106
d. National Credit Union Administration
Office of Consumer Financial Protection (OCFP)
Division of Consumer Compliance Policy and Outreach
1775 Duke Street
Alexandria, VA 22314
3. Air carriers
Asst. General Counsel for Aviation Enforcement & Proceedings
Aviation Consumer Protection Division
Department of Transportation
1200 New Jersey Avenue, S.E.
Washington, DC 20590
4. Creditors Subject to the Surface Transportation Board
Office of Proceedings, Surface Transportation Board
Department of Transportation
395 E Street, S.W.
Washington, DC 20423
5. Creditors Subject to the Packers and Stockyards Act, 1921
Nearest Packers and Stockyards Administration area supervisor
6. Small Business Investment Companies
Associate Deputy Administrator for Capital Access
United States Small Business Administration
409 Third Street, S.W., Suite 8200
Washington, DC 20416
7. Brokers and Dealers
Securities and Exchange Commission
100 F Street, N.E.
Washington, DC 20549
8. Federal Land Banks, Federal Land Bank Associations,
Federal Intermediate Credit Banks, and Production Credit
Farm Credit Administration
1501 Farm Credit Drive
McLean, VA 22102-5090
9. Retailers, Finance Companies, and All Other Creditors Not
Listed Above
Federal Trade Commission
Consumer Response Center
600 Pennsylvania Avenue, N.W.
Washington, DC 20580
(877) 382-4357