Fill - Free fillable BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION FORM In the PDF form

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BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION FORM

In the interest of maintaining the safety and security of our customers, employees and property,

___________________________ (the “Company”) will order a “consumer report” (a background report) or “investigative consumer

report" on you in connection with your employment application, and if you are hired, or if you already work for the Company, may order

additional background reports on you for employment purposes.

The background check company, _________________________________ (the "Background Check Company"), will prepare the

background report for the Company. The Background Check Company is located at ___________________________, and can be

reached by phone at ____________________ or at their Internet Web site address _____________________________.

The background report may contain information concerning your character, general reputation, personal characteristics, mode of living,

and credit standing. The types of information that may be ordered include but are not limited to: Social Security number verification;

criminal, public, educational and, as appropriate, driving records checks; verification of prior employment; reference, licensing and

certification checks; credit reports; drug testing results; and, if applicable, worker’s compensation injuries. Workers’ compensation

information will only be requested in compliance with federal Americans with Disabilities Act and/or any other applicable federal, state or

local laws and only after a conditional job offer is made. Credit history will only be requested when permitted by law and where such

information is substantially related to the duties and responsibilities of the position for which you are applying. The information may be

obtained from private and public record sources, including personal interviews with your associates, friends, and neighbors. (An

“investigative consumer report” is a background report that includes information from such personal interviews, except in California where

that term means any background report that is not a credit report.) The nature and scope of the most common form of investigative

consumer report is an investigation into your education and/or employment history conducted by the Background Check Company or

another outside organization.

You may request more information about the nature and scope of an investigative consumer report, if any, by telephoning the Company at

________________________. A summary of your rights under the Fair Credit Reporting Act is also being provided to you with this form.

The Fair Credit Reporting Act gives you specific rights in dealing with consumer reporting agencies. You will find these rights summarized

on A Summary of Your Rights Under the Fair Credit Reporting Act and A Summary of Your Rights Under the Provisions of California Civil

Code Section 1786.22 for California residents..

STATE LAW NOTICES

If you live or work for the Company in the states listed below, please note the following:

CALIFORNIA: You may view the file that the Background Check Company has for you, and order a copy of the file, upon submitting

proper identification and paying copying costs, by coming to their offices, during normal business hours and on reasonable notice, or by

certified mail or mail. You may also ask for a file-summary by telephone. The Background Check Company can answer questions

about information in your file, including any coded information. If you come in person, another person can come with you, so long as that

person can show proper identification.

MAINE: If you ask us, you have the right to know whether the Company ordered an investigative consumer report on you. You

may request the name, address, and telephone number of the nearest office for the Background Check Company. You will get this

information within 5 business days of our receipt of your request. You have the right to ask the Background Check Company for a free

copy of the report.

MARYLAND: If the Company obtains credit history information on you, it will be used to evaluate whether you would present an

unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.

MASSACHUSETTS/NEW JERSEY: If you submit a request to us in writing, you have the right to know whether the Company ordered an

investigative consumer report from the Background Check Company. You may inspect and order a free copy of the report by

contacting the Background Check Company.

MINNESOTA: If you submit a request to us in writing, you have the right to get from the Company a complete and accurate disclosure of

the nature and scope of the consumer report or investigative consumer report ordered, if any.

NEW YORK: If you submit a request to us in writing, you have the right to know whether the Company ordered a consumer report or an

investigative consumer report from the Background Check Company, and you will be provided with the name and address of the

Background Check Company. You may inspect and order a free copy of the reports by contacting the Background Check Company.

By signing below, you certify you have received a copy of Article 23A of the New York Correction Law is being provided with this form.

OREGON: If the Company obtains credit history information on you, it will be used to evaluate whether you would present an

unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.

WASHINGTON STATE: If you submit a request to us in writing, you have the right to get from the Company a complete and accurate

disclosure of the nature and scope of the investigative consumer report we ordered, if any. You also have the right to ask the

Background Check Company for a written summary of your rights under the Washington Fair Credit Reporting Act. If the Company

obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be used to evaluate whether you would

present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.

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AUTHORIZATION FOR BACKGROUND CHECKS

After carefully reading this Background Check Disclosure and Authorization form, I authorize the Company to order my

background report, including investigative consumer reports. I understand that the Company may rely on this authorization

to order additional background reports, including investigative cons

umer reports, during my employment without asking me

for my authorization again as allowed by law.

I also authorize the following agencies and entities to disclose to the Background Check Company and its agents all

information about or concerning me, including but not limited to: my past or present employers; learning

institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal,

state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; if applicable,

worker’s compensation injuries; all other private and public sector repositories of information; and any other person,

organization, or agency with any information about or concerning me. Workers’ compensation information will only be

requested in compliance with federal Americans with Disabilities Act and/or any other applicable federal, state or local

laws and only after a conditional job offer is made. The information that can be disclosed to the Background Check

Company and its agents includes, but is not limited to, information concerning my employment history, earnings history,

education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses and

substance abuse testing.

I agree the Company may rely on this authorization to order background reports, including investigative consumer

reports, from companies other than the Background Check Company without asking me for my authorization again as

allowed by law. I also agree that a copy of this form is valid like the signed original. I certify that all of the personal

information I provided is true and correct.

Last Name __________________________________ First ________________________ Middle ____________________

Maiden/Other Names _______________________________________________ Years Used _______________________

If you live or work for the Company in California, Minnesota or Oklahoma: Check this box if you would like a free

copy of your background check report: ☐

______________________________________________________________ _____/_______/________

Signature Date: (Month/Day/Year)

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BACKGROUND CHECK INFORMATION:

The information requested below is collected solely for the purpose of aiding the Company in running a background check

in conn

ection with your application for employment. The employer is requesting that you provide this information to assist

in conducting a thorough background check.

For residents of, or for jobs located in Utah, please do NOT provide your date of birth, social security number or driver’s

license number until instructed to do so by the Company.

First Name _______________________Middle Name __________________Last Name_________________________

Date of Birth ____/____/____ (Month/Day/Year)

Social Security Number ____________________________________________________

Driver’s License Number ______________________________ State Issuing License_________________________

Enter Any Other Names Used (including maiden names):

First Name _________________________Middle Name __________________Last Name_________________________

First Name _________________________Middle Name __________________Last

Name_________________________

Addresses Within The Past Seven Years (use a separate sheet as needed)

Present Street Address ___________________________________________________________

City/State/ZIP ___________________________________________________________________________

Prior Street Address _________________________________________________________________

From _____/_______/______ (Month/Day/Year) To _____/_______/______ (Month/Day/Year)

City/State/ZIP __________________________________________________________________________

Prior Street Address _________________________________________________________________

From _____/_______/______ (Month/Day/Year) To _____/_______/______ (Month/Day/Year)

City/State/ZIP __________________________________________________________________________

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Para informacion en espanol, visite

www.consumerfinance.gov/learnmore

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 the FCRA. For

more information, including information about additional

rights, go to www.consumerfinance.gov/learnmore

or write

to: Consumer Financial Protection Bureau, 1700 G Street

N.W., Washington, DC 2055

• 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 information.

• 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:

. a person has taken adverse action against you because

of information in your credit report;

. you are the victim of identity theft and place a fraud alert

in your file;

. your file contains inaccurate information as a result of

fraud;

. you are on public assistance;

. 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

www.consumerfinance.gov/learnmore

for additional information.

• 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 cred

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

www.consumerfinance.gov/learnmore

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

www.consumerfinance.gov/learnmore

• 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 from the

lists these offers are based on. You may opt-out with the

nationwide credit bureaus at 1-888-567-8688.

• 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

www.consumerfinance.gov/learnmore

Stat

es 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 protection agency or your state

Attorney General. For information about your federal

rights, contact:

Page 5 of 7 v1112

TYPE OF BUSINESS: CONTACT:

1.a. Banks, savings associations, and credit unions with total

ass

ets of over $10 billion and their affiliates.

b. Such affiliates that are not banks, savings associations, or

cred

it 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 –

FCRA

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 foreig

nks (other than federal branches, federal agencies, and

Insured State Branches of Foreign Banks), commerci

nding companies owned or controlled by foreign ba

nks,

d organizations operating under section 25 or 25A of th

Federal Reserve Act

c. No

nmember Insured Banks, Insured State Branche

s of

Forei

gn 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 Protection (OCP)

Division of Consumer Compliance and Outreach (DCCO)

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, SW, 8

Floor

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,

Fed

eral Intermediate Credit Banks, and Production Cred

Associations

Farm Credit Administration

1501 Farm Credit Drive

McLean, VA 22102-5090

9. Retailers, Finance Companies, and All Other Creditors Not

Listed Above

FTC Regional Office for region in which the creditor operates or

Federal Trade Commission: Consumer Response Center –

FCRA

Washington, DC 20580

(877

) 382-4357

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A Summary of Your Rights

Under the Provisions of California Civil Code Section 1786.22

The Investigative Consumer Reporting Agencies Act (ICRA) 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 ICRA, at the California Privacy Protection web site

(http://www.privacy.ca.gov/icraa.htm). The ICRA gives you specific rights, as outlined below. You may

have additional rights under federal law. You may contact a state or local consumer protection agency or

a state attorney general to learn those rights.

(a) An investigative consumer reporting agency shall supply files and information required under Section

1786.10 during normal business hours and on reasonable notice.

(b) Files maintained on a consumer shall be made available for the consumer's visual inspection, as

follows:

(1) In person, if he appears in person and furnishes proper identification. A copy of his file shall also be

available to the consumer for a fee not to exceed the actual costs of duplication services provided.

(2) By certified mail, if he makes a written request, with proper identification, for copies to be sent to a

specified addressee. Investigative consumer reporting agencies complying with requests for certified

mailings under this section shall not be liable for disclosures to third parties caused by mishandling of

mail after such mailings leave the investigative consumer reporting agencies.

(3) A summary of all information contained in files on a consumer and required to be provided by Section

1786.10 shall be provided by telephone, if the consumer has made a written request, with proper

identification for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or

charged directly to the consumer.

deemed sufficient to identify a person. Such information includes documents such as a valid driver’s

license, social security account number, military identification card, and credit cards. Only if the consumer

is unable to reasonably identify himself with the information described above, may an investigative

consumer reporting agency require additional information concerning the consumer's employment and

personal or family history in order to verify his identity.

(d) The investigative consumer reporting agency shall provide trained personnel to explain to the

consumer any information furnished him pursuant to Section 1786.10.

(e) The investigative consumer reporting agency shall provide a written explanation of any coded

information contained in files maintained on a consumer. This written explanation shall be distributed

whenever a file is provided to a consumer for visual inspection as required under Section 1786.22.

(f) The consumer shall be permitted to be accompanied by one other person of his choosing, who shall

furnish reasonable identification. An investigative consumer reporting agency may require the consumer

to furnish a written statement granting permission to the consumer reporting agency to discuss the

consumer's file in such person's presence.

Page 7 of 7 v1112

NEW YORK CORRECTION LAW

ARTICLE 23-A

LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY

CONVICTED OF ONE OR MORE CRIMINAL OFFENSES

Section 750. Definitions.

751. Applicability.

752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited.

753. Factors to be considered concerning a previous criminal conviction; presumption.

754. Written statement upon denial of license or employment.

755. Enforcement.

§750. Definitions. For the purposes of this article, the following terms shall have the following meanings:

(1) "Public agency" means the state or any local subdivision thereof, or any state or local department, agency, board or commission.

(2) "Private employer" means any person, company, corporation, labor organization or association which employs ten or more

persons.

(3) "Direct relationship" means that the nature of criminal conduct for which the person was convicted has a direct bearing on his

fitness or ability to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in

question.

(4) "License" means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions

or instrumentalities as a condition for the lawful practice of any occupation, employment, trade, vocation, business, or profession.

Provided, however, that "license" shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire

any explosive, pistol, handgun, rifle, shotgun, or other firearm.

(5) "Employment" means any occupation, vocation or employment, or any form of vocational or educational training. Provided,

however, that "employment" shall not, for the purposes of this article, include membership in any law enforcement agency.

§751. Applicability. The provisions of this article shall apply to any application by any person for a license or employment at any public or

private employer, who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any

license or employment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdiction

preceded such employment or granting of a license, except where a mandatory forfeiture, disability or bar to employment is imposed by

law, and has not been removed by an executive pardon, certificate of relief from disabilities or certificate of good conduct. Nothing in this

article shall be construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with an

application for employment made by a prospective employee or previously made by a current employee.

§752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited. No application for

any license or employment, and no employment or license held by an individual, to which the provisions of this article are applicable, shall

be denied or acted upon adversely by reason of the individual's having been previously convicted of one or more criminal offenses, or by

reason of a finding of lack of "good moral character" when such finding is based upon the fact that the individual has previously been

convicted of one or more criminal offenses, unless:

(1) There is a direct relationship between one or more of the previous criminal offenses and the specific license or employment

sought or held by the individual; or

(2) the issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk

to property or to the safety or welfare of specific individuals or the general public.

§753. Factors to be considered concerning a previous criminal conviction; presumption.

1. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall

consider the following factors:

(a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons

previously convicted of one or more criminal offenses. (b) The specific duties and responsibilities necessarily related to the

license or employment sought or held by the person. (c) The bearing, if any, the criminal offense or offenses for which the

person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities.

(d) The time which has elapsed since the occurrence of the criminal offense or offenses.

(e) The age of the person at the time of occurrence of the criminal offense or offenses.

(f) The seriousness of the offense or offenses.

(g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct.

(h) The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of

specific individuals or the general public.

2. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall

also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which

certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein.

§754. Written statement upon denial of license or employment. At the request of any person previously convicted of one or more

criminal offenses who has been denied a license or employment, a public agency or private employer shall provide, within thirty days of a

request, a

written statement setting forth the reasons for such denial.

§755. Enforcement.

1. In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to

article seventy-eight of the civil practice law and rules.

2. In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights

pursuant to the powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city

commission on human rights.

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