Fillable Background Questionnaire City Applicant

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Background Questionnaire City Applicant

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BROWSE CITY (AR) FORMS

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Revised April 2018 P a g e 1 | 7
Employment with the City of Little Rock
Name: __________________________________________________________
Department: ______________________________________________________
Received by (HR): _________________________ Date: _________________
Fill out this questionnaire completely and accurately.
All statements in this questionnaire are subject to verification.
If space provided is inadequate, add additional pages and identify information by
name and section number.
Do not misstate or omit material facts since the statements made are subject to
verification.
Any question that does not pertain to you, please indicate with the letters N/A,
meaning not applicable.
Complete all spaces provided (or indicate N/A) for pages 2-3.
You must sign and/or initial pages 4-5 in the indicated spaces; failure to sign is
sufficient to disqualify you
from further consideration.
CITY OF LITTLE ROCK
Background Information Booklet
Revised April 2018 P a g e 2 | 7
BACKGROUND INFORMATION FORM – (PERSONAL INFORMATION)
Today's Date: / / _______
FULL LEGAL NAME: ______________________________________________________________
LAST FIRST MIDDLE
ALIAS(S): ________________________________________________________________________
NICKNAME(S): ________________________ __________________________________________
MAIDEN NAME: _____________________________ _____________________________________
List any other names you have used (in the last 10 years) or been known by, and give reasons for the
change (if none, so state).
___________________________________________________________________________________
SOCIAL SECURITY NUMBER: __________________________
BIRTH DATE: ___________________ DRIVER'S LICENSE NUMBER: __________________
MONTH/DAY/YEAR
*STATE: _____________________________________
PRESENT ADDRESS: _______________________________________________________________
FULL STREET ADDRESS APARTMENT
___________________________________________________________________________________
CITY STATE ZIP
PHONE: _____________________________________ ________________________________
HOME TELEPHONE MESSAGE TELEPHONE
SPOUSE'S NAME: __________________________________________________________________
SEX OFFENDER STATUS:
Are you required by law to register in any state? Yes No
Are you required by law to register as a sex offender in Arkansas? Yes No
If yes, are you compliant with the Sex Offender Acknowledgment Form?
Yes No ……
If yes, under what name are you registered:
________________________________
Revised April 2018 P a g e 3 | 7
List your HOME ADDRESS(ES) for the previous 7 years, if different from your current address:
Date From
Date To
Street Address
City
Zip
CRIMINAL VIOLATIONS - If you have ever been convicted of any CRIMINAL Violations of law
in this State or elsewhere, provide the information requested
below for each incident:
Are you currently on probation?
Yes □
No
□
If yes, do you regularly check in with your Probation Officer?
Yes □
No
□
Please list your Probation Officer’s name _______________________________________ phone number________________
Date
Charge
Age at
Time
Location
Disposition
(Fine, Sentence,
Release)
Agency Involved:
City,
State,
Federal
TRAFFIC VIOLATIONS (including DWI and DUI violations)
If you have been convicted of any TRAFFIC Violations within the Last Five (5) Years in this State or
elsewhere, provide the information requested below for each incident. Please remember to include N/A if
you do not have any traffic violation.
Date
Charge
Age at
Time
Location
Disposition
(Fine, Sentence,
Release)
Agency Involved:
City,
State,
Federal
Revised April 2018 P a g e 4 | 7
DISCLOSURE AND AUTHORIZATION
I understand and agree that (place initial in the box to the left of each paragraph):
Initial Here
The information supplied in my application documents, was submitted by me, and all information is
true and correct, to the best of my knowledge. I am to abide by all rules and regulations of the City
of Little Rock. The City of Little Rock has my authorization to thoroughly investigate my work and
personal history. The information supplied by me, regarding my Criminal History, Motor Vehicle
Record(s) – if applicable, Residence History, and References (if applicable), will be utilized as
part of the processing procedures. A background check will be conducted to verify the truthfulness
and accuracy of the information submitted. I will hold no person liable for giving or receiving
information in this investigation.
Initial Here
I hereby certify that my personal history statement and all attachments to it contain no false
information and are complete, truthful and accurate to the best of my knowledge. I understand that
should an investigation disclose misrepresentation or falsification of any information on this form
or its attachments, my application may be rejected, my name removed from an eligible register, and
if I am already employed, I may be dismissed from city employment, and I may be disqualified from
applying for future employment with the City of Little Rock.
Initial Here
I hereby authorize the City of Little Rock and Courthouse Concepts to make a thorough check of
my Criminal History, Motor Vehicle Record(s) – if applicable, Residence History, and References.
I release from liability all persons and employers supplying that information. I release and indemnify
the City of Little Rock and Courthouse Concepts against any liability that might result from making
such background checks. A copy of this form is as valid as the original.
Initial Here
In connection with my application for employment (including contract for services or volunteer
services) or tenancy with The City of Little Rock (Little Rock, AR), I authorize the use of
requested Consumer Reports. These consumer reports (investigative consumer reports in
California) may include the following types of information: names and dates of previous
employers, work experience, education, accidents, licensure, etc. I further understand that such
reports may contain public record information such as, but not limited to: my driving record,
criminal records, etc., from federal, state and other agencies which maintain such records.
Initial Here
In addition, investigative consumer reports as defined by the federal Fair Credit Reporting Act,
gathered from personal interviews with former employers and other past or current associates
of mine to gather information regarding my work performance, character, general reputation
and personal characteristics may be obtained.
Initial Here
I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY
CONTACTED BY THE CONSUMER REPORTING AGENCY TO FURNISH THE
ABOVE
‐
MENTIONED INFORMATION.
Initial Here
I have the right to make a request to the consumer reporting agency: CourtHouse Concepts, 16
W. Center St., Fayetteville, AR 72701; telephone 479 582‐3660. CourtHouse Concepts, upon
proper identification, 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 our behalf, will
provide a complete and accurate disclosure of the nature and scope of the investigation covered
by the investigative consumer report(s); and the recipients of any 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 your
obtaining the above information from the agency. You may view their privacy policy at their
website: www.courthouseconcepts.com.
Revised April 2018 P a g e 5 | 7
Initial Here
I hereby authorize procurement of consumer report(s) and investigative consumer report(s). If
hired (or contracted), this authorization shall remain on file and shall serve as ongoing
authorization for you to procure consumer reports at any time during my employment (or
contract) period.
Initial Here
I acknowledge that I have been provided a copy of consumer’s rights under the Fair Credit
Reporting Act (please detach the following two pages for your records).
Applicant’s Signature: __________________________________________________________________
click to sign
signature
click to edit
Revised April 2018 P a g e 6 | 7
Applicant: Please detach this page and the next page
and keep for your records.
Para informacion en espanol, visite www.ftc.gov/credit o escribe a la FTC Consumer Response Center,
Room 130-A 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.
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.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade
Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.
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, by September 2005 all consumers will be entitled to one free disclosure every 12
months upon request from each nationwide credit bureau and from nationwide specialty
consumer reporting agencies. See www.ftc.gov/credit 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 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 www.ftc.gov/credit
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
Revised April 2018 P a g e 7 | 7
1/7/2013
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.ftc.gov/credit.
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 1-888-5-
OPTOUT (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.ftc.gov/credit.
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. Federal enforcers are:
TYPE OF BUSINESS:
CONTACT:
Consumer reporting agencies, creditors and others not listed
below
Federal Trade Commission: Consumer Response Center - FCRA
Washington, DC 20580 1-877-382-4357
National banks, federal branches/agencies of foreign banks (word
"National" or initials "N.A." appear in or after bank's name)
Office of the Comptroller of the Currency Compliance
Management, Mail Stop 6-6 Washington, DC 20219 800-613-
6743
Federal Reserve System member banks (except national banks,
and federal branches/agencies of foreign banks)
Federal Reserve Consumer Help (FRCH) P O Box 1200
Minneapolis, MN 55480 Telephone: 888-851-1920 Website
Address: www.federalreserveconsumerhelp.gov Email Address:
ConsumerHelp@FederalReserve.gov
Savings associations and federally chartered savings banks (word
"Federal" or initials "F.S.B." appear in federal institution's name)
Office of Thrift Supervision Consumer Complaints Washington,
DC 20552 800-842-6929
Federal credit unions (words "Federal Credit Union" appear in
institution's name)
National Credit Union Administration 1775 Duke Street
Alexandria, VA 22314 703-519-4600
State-chartered banks that are not members of the Federal
Reserve System
Federal Deposit Insurance Corporation Consumer Response
Center, 2345 Grand Avenue, Suite 100 Kansas City, Missouri
64108-2638 1-877-275-3342
Air, surface, or rail common carriers regulated by former Civil
Aeronautics Board or Interstate Commerce Commission
Department of Transportation , Office of Financial Management
Washington, DC 20590 202-366-1306
Activities subject to the Packers and Stockyards Act, 1921
Department of Agriculture
Office of Deputy Administrator - GIPSA Washington, DC 20250 202-720-7051
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Background Questionnaire City Applicant

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Completed 18 July 2020

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