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DISCLOSURE AND AUTHORI ZATION FORM Servant HR, (the (Servant HR)

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1
DISCLOSURE AND AUTHORI
ZATION FORM
Servant HR, (the
“Company”) may request background information about you from a consumer reporting
agency in connection with your employment application and for employment purposes. This information may
be obtained in the form of consumer reports and/or investigative consumer reports. These reports may be
obtained at any time after receipt of your authorization and, if you are hired by the Company, throughout your
employment.
Precise Hire, I
nc. will obtain the reports for the Company. Precise Hire, Inc. is located at 6841 Virginia Pkwy,
#177, McKinney, TX 75071, and can be contacted at 866-773-5486. The reports may contain information
bearing on your character, general reputation, personal characteristics, mode of living and credit standing. The
types of information that may be obtained include, but are not limited to: social security number verifications;
credit reports; criminal records checks; public court records checks; driving records checks; educational records
checks; employment verifications; personal and professional references checks; licensing and certification
records checks; drug testing results; etc. The information contained in the reports will be obtained from private
and public record sources, including, as appropriate, personal interviews with sources, such as neighbors,
friends, associates and former employers.
You may request
more information about the nature and scope of any investigative consumer reports by
contacting the Company at: 317.585.1688 (10412 Allisonville Rd. STE 206, Fishers, IN 46038). A summary of
your rights under the Fair Credit Reporting Act is also being provided to you.
ADDITIONAL STATE LAW
NOTICES
If you are a California, Maine, New York or Washington applicant, please also note:
CALIFORNIA: Under section 1786.22 of the California Civil Code, you may view the file maintained on you by Precise
Hire during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and
paying the costs of duplication services, by appearing at Precise Hire’s offices in person, during normal business hours and
on reasonable notice, or by mail. You may also receive a summary of the file by telephone, upon submitting proper
identification. Precise Hire has trained personnel available to explain your file to you, including any coded information. If
you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification.
NEW YORK: You have the right, upon request, to be informed of whether or not a consumer report was requested. If a
consumer report is requested, you will be provided with the name and address of the consumer reporting agency furnishing
the report. You may inspect and receive a copy of the report by contacting that agency.
MAINE: You have the right, upon request, to be informed of whether an investigative consumer report was requested, and
if one was requested, the name and address of the consumer reporting agency furnishing the report. You may request and
receive from the Company, within five business days of our receipt of your request, the name, address and telephone
number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an investigative
consumer report concerning you. You also have the right, under Maine law, to request and promptly receive from all such
agencies copies of any such reports.
WASHINGTON STATE: If we request an investigative consumer report, you have the right, upon written request made
within a reasonable period of time after your receipt of this disclosure, to receive from us a complete and accurate
disclosure of the nature and scope of the investigation we requested. You also have the right to request from the consumer
reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
2
AUTHORIZATION
I have carefully read and understand this Disclosure and Authorization form and the attached summary of
rights under the Fair Credit Reporting Act. By my signature below, I consent to the release of consumer
reports and investigative consumer reports prepared by Precise Hire, Inc. to Servant HR, (the
“Company”) and its designated representatives and agents. I understand that if the Company hires
me, my consent will apply, and the Company may obtain reports, throughout my employment.
I also understand that information contained in my job application or otherwise disclosed by me before or
during my employment, if any, may be used for the purpose of obtaining consumer reports and/or
investigative consumer reports.
By my signature below, I authorize law enforcement agencies, learning institutions (including public and
private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts
(federal, state and local), motor vehicle records agencies, my past or present employers, the military,
and other individuals and sources to furnish any and all information on me that is requested by the
consumer reporting agency.
By my signature below, I certify the information I provided on this form is true and correct. I agree that
this Disclosure and Authorization form in original, faxed or photocopied form, will be valid for any reports that
may be requested by or on behalf of the Company.
California, Minnesota
or Oklahoma applicants
only
--
You
will be provided
with a free copy of
any consumer reports or investigative consumer reports obtained on you if you check the box below.
I wish to receive a free copy of the report.
Full Name: _______________________________________ Other Names Used: _______________________
Social Security No.*:_______________________________
Date of Birth*: ___________________________
Present Address: ___________________________________________________________________________
Street Address
___________________________________________________________________________
City State Zip
Driver’s License #: _______________________________________________ State ___________________
Have you ever been convicted of ANY crime? No
Yes***
*** If yes, please provide city/state and year of conviction, along with details of the conviction (misdemeanor,
felony, etc).
______________________________________________________________________________________
______________________________________________________________________________________
Applicant Signature ______________________________________ Date _________________________
* This information will be used only for background screening purposes and will not be taken into consideration in any
employment decisions.
click to sign
signature
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3
Para información en español, 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 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 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
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:
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 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
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
4
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 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
agencies:
CONSUMERS HAVE THE RIGHT TO OBTAIN A SECURITY FREEZE
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
credit.
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
5
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 www.consumerfinance.gov/learnmore.
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:
6
TYPE OF BUSINESS:
CONTACT:
1.a. Banks, savings associations, and credit unions with total
assets of over $10 billion and their affiliates
b. Su
ch 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. Fed
eral 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. St
ate 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. No
nmember Insured Banks, Insured State Branches of
Foreign Banks, and insured state savings associations
d. Fe
deral Credit Unions
a. Office of the Comptroller of the Currency
Customer Assistance Group
1301 McKinney Street, Suite 3450
Houston, TX 77010-9050
b. Fed
eral Reserve Consumer Help Center
P.O. Box 1200
Minneapolis, MN 55480
c. FD
IC Consumer Response Center
1100 Walnut Street, Box #11
Kansas City, MO 64106
d. Na
tional 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
Associations
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
7
Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la
Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
Remedying the Effects of Identity Theft
You are receiving this information because you have notified a consumer reporting
agency that you believe that you are a victim of identity theft. Identity theft occurs when
someone uses your name, Social Security number, date of birth, or other identifying information,
without authority, to commit fraud. For example, someone may have committed identity theft by
using your personal information to open a credit card account or get a loan in your name. For
more information, visit www.consumerfinance.gov/learnmore or write to: Consumer Financial
Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
The Fair Credit Reporting Act (FCRA) gives you specific rights when you are, or believe
that you are, the victim of identity theft. Here is a brief summary of the rights designed to help
you recover from identity theft.
1. You have the right to ask that nationwide consumer reporting agencies place “fraud
alerts” in your file to let potential creditors and others know that you may be a victim
of identity theft. A fraud alert can make it more difficult for someone to get credit in your
name because it tells creditors to follow certain procedures to protect you. It also may delay
your ability to obtain credit. You may place a fraud alert in your file by calling just one of
the three nationwide consumer reporting agencies. As soon as that agency processes your
fraud alert, it will notify the other two, which then also must place fraud alerts in your file.
• Equifax: 1-800-525-6285; www.equifax.com
• Experian: 1-888-397-3742; www.experian.com
• TransUnion: 1-800-680-7289; www.transunion.com
An initial fraud alert stays in your file for at least one year. An extended alert stays in your
file for seven years. To place either of these alerts, a consumer reporting agency will require
you to provide appropriate proof of your identity, which may include your Social Security
number. If you ask for an extended alert, you will have to provide an identity theft report.
An identity theft report includes a copy of a report you have filed with a federal, state, or
local law enforcement agency, and additional information a consumer reporting agency may
require you to submit. For more detailed information about the identity theft report, visit
www.consumerfinance.gov/learnmore.
2. You have the right to free copies of the information in your file (your “file disclosure”).
An initial fraud alert entitles you to a copy of all the information in your file at each of the
three nationwide agencies, and an extended alert entitles you to two free file disclosures in a
12-month period following the placing of the alert. These additional disclosures may help
you detect signs of fraud, for example, whether fraudulent accounts have been opened in
your name or whether someone has reported a change in your address. Once a year, you also
have the right to a free copy of the information in your file at any consumer reporting agency,
if you believe it has inaccurate information due to fraud, such as identity theft. You also
8
have the ability to obtain additional free file disclosures under other provisions of the FCRA.
See www.consumerfinance.gov/learnmore.
3. You have the right to obtain documents relating to fraudulent transactions made or
accounts opened using your personal information. A creditor or other business must give
you copies of applications and other business records relating to transactions and accounts
that resulted from the theft of your identity, if you ask for them in writing. A business may
ask you for proof of your identity, a police report, and an affidavit before giving you the
documents. It may also specify an address for you to send your request. Under certain
circumstances a business can refuse to provide you with these documents. See
www.consumerfinance.gov/learnmore.
4. You have the right to obtain information from a debt collector. If you ask, a debt
collector must provide you with certain information about the debt you believe was incurred
in your name by an identity thief – like the name of the creditor and the amount of the debt.
5. If you believe information in your file results from identity theft, you have the right to
ask that a consumer reporting agency block that information from your file. An identity
thief may run up bills in your name and not pay them. Information about the unpaid bills
may appear on your consumer report. Should you decide to ask a consumer reporting agency
to block the reporting of this information, you must identify the information to block, and
provide the consumer reporting agency with proof of your identity and a copy of your
identity theft report. The consumer reporting agency can refuse or cancel your request for a
block if, for example, you don’t provide the necessary documentation, or where the block
results from an error or a material misrepresentation of fact made by you. If the agency
declines or rescinds the block, it must notify you. Once a debt resulting from identity theft
has been blocked, a person or business with notice of the block may not sell, transfer, or
place the debt for collection.
6. You also may prevent businesses from reporting information about you to consumer
reporting agencies if you believe the information is a result of identity theft. To do so,
you must send your request to the address specified by the business that reports the
information to the consumer reporting agency. The business will expect you to identify what
information you do not want reported and to provide an identity theft report.
7. The following FCRA right applies with respect to nationwide consumer reporting agencies:
CONSUMERS HAVE THE RIGHT TO OBTAIN A SECURITY FREEZE
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
9
approval of any subsequent request or application you make regarding a new loan, credit,
mortgage, or any other account involving the extension of credit.
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.
To learn more about identity theft and how to deal with its consequences, visit
www.consumerfinance.gov/learnmore, or write to the Consumer Financial Protection Bureau.
You may have additional rights under state law. For more information, contact your local
consumer protection agency or your state Attorney General.
In addition to the new rights and procedures to help consumers deal with the effects of
identity theft, the FCRA has many other important consumer protections. They are described in
more detail at www.consumerfinance.gov/learnmore.
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DISCLOSURE AND AUTHORI ZATION FORM Servant HR, (the (Servant HR)

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Completed 16 December 2020

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