Applicants: Please keep pages 1 through 5 for your records
For the benefit of CGU and employees, CGU has a policy of performing pre-employment background
screening on job applicants as a condition of employment. This policy is a business practice that
protects everyone by helping to promote a safe and profitable workplace. All pre-employment
inquiries are limited to information that affects job performance and the workplace. It is conducted in
accordance with applicable federal and state laws, including the Fair Credit Reporting Act (FCRA).
The screening will be conducted by ScreeningOne, Inc., and outside agency. Company may obtain a
consumer credit report and/or an investigative consumer report on you as an applicant or during
the course of employment.
If a credit check is required for the position, a separate waiver form will be provided.
1. The report consists of information deemed to have a bearing on job performance, and may
include information from public and private sources, public records, former employers and
references. The scope of the report may include information concerning driving record, civil
and criminal court records, credit, worker’s compensation records, education, credentials,
identity, past addresses, social security number, previous employment and personal
2. The report may also include reference checks
from former employers, co-workers or
Any past employment reference check is limited to job related information. These
are known as an “investigative consumer report.” This type of report is legally de
fined as a
report based upon interviews that may contain information relating to my character, general
reputation, personal characteristics or mode of living. You have the right to request additional
disclosures of the nature and scope of the investigation and statement of your rights. To
receive this information, or to inspect any files concerning such a report or to determine if a
report on you has been requested, you may contact Screening One, Inc. at (888-327-6511) or
2233 W. 190
St. Torrance, CA 90504
3. In using a report for employment purposes, before taking any adverse action based in whole
or in part on the report, the person intending to take such adverse action shall provide to the
consumer to whom the report relates a copy of the report and a description in writing of the
rights of the consumer under the title, as prescribed by the Federal Trade Commission section
California Provisions: In California, any report concerning a consumer’s character,
personal characteristics or mode of living is defined as an In
vestigative Consumer
Report. In
addition to your rights under federal law, you have the following additional rights:
You have the right to inspect Screening One’s files during normal business hours and on
reasonable notice; the inspection may be in person, by certified mail, or by telephone if the
individual shows proper identification and pays for any
copying charges; the applicant may be
accompanied by one other person who mus
t show proper identification; and trained Screening
One personnel will explain any of the information in the report and will provide written
explanation for nay coded information.
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 freeze” on 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
State member banks, branches and agencies of foreign bank
(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
I request a free copy of any consumer Report, Investigative Report or Credit Report on me that is
Yes No
I, , hereby consent and
authorize CGU and/or ScreeningOne on the employer’s behalf, to prepare each
report as defined above for employment purposes before employment or anytime after employment.
Signature: Date:
I in connection with my application for employment with Claremont
University (CGU), hereby authorize CGU and ScreeningOne, Inc. to perform a pre-
employment background screening check (including future screenings for retention, reassignment of
promotion, if applicable, and unless revoked by Applicant in writing). I understand and agree to the
1. A background check is not only for the benefit of CGU as a sound business practice, but also
for the bene
fit of all employees. It is no reflection
on an applicant. I have read, understand
and signed t
he separate Disclosure
concerning my rights.
All reports are confidential, and provided to CGU for employment decisions
only. Consumer
credit information including credit reports are obtained in strict compliance with the Fair Credit
Reporting Act, the Americans with Disabilities Act (ADA), anti-discrimination and privacy laws
and all other
ederal and state laws.
I may rev
iew or obtain a copy of my report as provided by law. ScreeningOne may be
contacted by writing to: Screening One, Inc., 2233 W. 190
St. Torrance, CA 90504
4. I authorize and release people, companies, references, current and former employers,
schools, credit bureaus, municipal, county, state and federal agencies and courts, and
agencies that provide motor vehicle records to provide all information that is requested by
CGU and/or Screening One.
I further release all of the above, including CGU and ScreeningOne, to the full extent
permitted by law, from any liability or claims arisi
ng from retrieving and reporting inform
concerning me.
I agree that an electrinic copy of this document shall be as valid as the original.
Candidate Signature: Date:
____________ ____________
Last Name First Name Middle Name
/ /
Date of Birth Social Security Number
Former Name (s) / Date of Change
Hand written signature required
In connectio
n with my application for employment at Claremont Graduate University, (including future
screening for retention, reassignment or promotion, if applicable, and unless revoked by applicant in
writing), I authorize the state Department of Motor Vehicles, Driver’s Records Office, to release my
driving record to any party or agency contacted by this employer or its agent Screening One, Inc.
_________________ _________________________ ________________
Last Name First Name
Middle Name
Date of Birth Social Security Number Driver’s License # State of Issue
Exact Name on Drivers License (if different than above)
Signature Date
Please p
rovide all address where you have lived for the past seven years, include county and zip code.
Current Address:
Apt# ______________
___ ___________ ____________________
City State Zip County
Former Address:
___ ___________ ____________________
City State Zip County
Former Address:
___ ___________ ____________________
City State Zip County
Former Address:
___ ___________ ____________________
City State Zip County
Former Address:
___ ___________ ____________________
City State Zip County
Hand written signature required