BACKGROUND CHECK AUTHORIZATION
1. Notice
A consumer report or an investigative consumer report may be obtained on you for employment purposes. It may
include information as to your character, general reputation, personal characteristics and mode of living. You have a
right to request disclosure of the nature and scope of the report.
2. Authorization - Please write legibly
I, ________________________ _______________________ ____________________
Legal Last Name (Print) First Name (Print) Middle Name (Print)
________________________________________________________________________
Current Address, City, State/Province, Zip Code & Country if outside U.S. (Print)
_______________ ______________________________________________________
Date of Birth Other Names Used (Including Maiden Name) – do not include SCA persona
____________________ ____________________ ____________________
Social Security Number Driver’s License Number State/Province of Issuance
_______________ _____________________
Gender State/Province of Volunteer
______________________ _______________________________
Membership Number Kingdom
(a) I hereby authorize The Society for Creative Anachronism in its sole discretion, to obtain a consumer report or an
investigative consumer report for purposes of evaluating my application for employment
(b) I also understand that upon my written request, within a reasonable time after receipt of this disclosure, a complete
and accurate disclosure of the nature and scope of the investigation requested will be provided to me in writing.
(c) I also understand that before taking any adverse action based in whole or in part on the Report, The Society for
Creative Anachronism shall provide to me a copy of the report and a description in writing of my rights under the
Fair Credit Reporting Act.
Date: _______________ By: ___________________________________________
Name (printed) __________________________________
CALIFORNIA, OKLAHOMA, MASSACHUSETTS, MINNESOTA and NEW JERSEY RESIDENTS ONLY: If
you are a current California, Oklahoma, Massachusetts, Minnesota or New Jersey resident and would like to request a
copy of your Consumer Report or Investigative Consumer Report, please check the box and provide your email address
(required)
EMAIL ADDRESS: ______________________________________________________________
PENNSYLVANIA RESIDENTS/VOLUNTEER
TO SUBMIT BY EMAIL: Membership@sca.org Rev: 11/19
