Danville Area Community College (DACC)
DISCLOSURE AND AUTHORIZATION FOR CONSUMER REPORTS
(BHR BASIC)
Disclosure
DACC has contracted with Bushue Background Screening in connection with my application for employment (including
contract or volunteer services), I understand consumer reports will be requested by you (“End-User”). These reports may
include, as allowed by law, the following types of information, as applicable: names and dates of previous employers, work
experience, education, accidents, licensure, credit (as allowed by law – where required, you will be presented with additional
disclosures), etc. I further understand that such reports may contain public record information such as, but not limited to: my
driving record, judgments, evictions, criminal records, etc., from federal, state, and other agencies that maintain such records.
If I am hired, I understand that my employer can use this disclosure and authorization to continue to obtain such consumer
reports throughout my employment, contract period or volunteer service.
Authorization
I,
, hereby authorize procurement of consumer report(s) and investigative consumer
report(s) by End-User. If hired (or contracted), this authorization shall remain on file and shall serve as ongoing
authorization for End-User to procure such reports at any time during my employment, contract, or volunteer period. I
authorize without reservation, any person, business or agency contacted by the consumer reporting agency to furnish the
above-mentioned information. This authorization is conditioned upon the following representations of my rights:
I understand I have the right to make a request to the consumer reporting agency: Bushue Human Resources, Inc. d/b/a
Bushue Background Screening (“Agency”), 302 East Jefferson Avenue, Suite B, Effingham, IL 62401, telephone number
(217) 342-3042 or toll free at (877) 342-3042 , upon proper identification, to obtain copies of any reports furnished to End-
User by the Agency and 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 End-User’s behalf, will provide a complete and accurate disclosure
of the nature and scope of the investigation covered by any investigative consumer report(s). The Agency will also disclose
the recipients of any such 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
End-User obtaining the above information from the Agency. I understand that I can dispute, at any time, any information
that is inaccurate in any type of report with the Agency. I may view the Agency’s privacy policy at their website:
www.bushuebackgroundscreening.com.
I understand that if the End-User is located in California, Minnesota or Oklahoma, that I have the right to request a copy of
any report End-User receives on me at the time the report is provided to End-User. By checking the following box, I request
a copy of all such reports be sent to me. Check here:
As a California applicant, I understand that I have the right under Section 1786.22 of the California Civil Code to contact the
Agency during reasonable hours (9:00 a.m. to 5:00 p.m. (CTZ) Monday through Friday) to obtain all information in
Agency’s file for my review. I may obtain such information as follows: 1) In person at the Agency’s offices, which address
is listed above. I can have someone accompany me to the Agency’s offices. Agency may require this third party to present
reasonable identification. I may be required at the time of such visit to sign an authorization for the Agency to disclose to or
discuss Agency’s information with this third party; 2) By certified mail, if I have previously provided identification in a
written request that my file be sent to me or to a third party identified by me; 3) By telephone, if I have previously provided
proper identification in writing to Agency; and 4) Agency has trained personnel to explain any information in my file to me
and if the file contains any information that is coded, such will be explained to me.
I understand that if I am applying for employment in New York, that I have the right to receive a copy of Article 23-A of the
New York Correction Law (initial if this applies).
I understand that if the report is provided to an employer in the State of Washington, that I can contact the following office
for more information regarding my rights under Washington state law in regard to these reports: State of Washington
Attorney General, Consumer Protection Division, 800 5
th
Ave, Ste. 2000, Seattle, Washington 98104-3188, (206) 464-7744.
I understand that I have rights under the Fair Credit Reporting Act, and I acknowledge receipt of the Summary of Rights
(initials).
