In connection with your application for employment or continued employment with Metropolitan State University of Denver (MSU Denver), MSU Denver may request
background information about you from a consumer-reporting agency. The information that may be obtained is defined below. The University will consider the information
confidential and will use the information solely for employment-related purposes.
HireRight, Inc., the University's authorized consumer reporting agency, will obtain the reports for MSU Denver. HireRight, Inc. is located at 5151 California, Irvine, CA 92617,
and can be contacted at 800-400-2761. The types of information that may be obtained include: a social security number verification, a criminal conviction records check, and
a sexual offender registry check. If the position description includes a requirement for driving, a Department of Motor Vehicles records check may be required. If the position
description includes access to University funds or resources, a credit report may be required. The information will be obtained from private and public record sources. A
summary of your rights under the Fair Credit Reporting Act is being provided to you.
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 criminal conviction records, sex offender registry records, social security verification records, and if related to the position description, Department of
Motor Vehicle and credit records, prepared by a consumer reporting agency, such as Hire Right, Inc., to MSU Denver and its designated representatives and agents. I
understand and agree that MSU Denver may request these records about me for employment-related purposes as related to this position, one time during the course of my
application for this position. In case of changes in employment, the university retains the right to request additional background checks; in such case, an additional authorization
form will be required. I understand that my authorization for and consent to this background investigation will be valid until the authorized checks are completed.
By my signature, I authorize, request and require any persons, government agencies, or any other public or private entity contacted by MSU Denver, Hire Right, or their
agents to disclose and release to Hire Right and MSU Denver the above-specified records.
By my signature, I certify the information I provided on this form is true and correct. I agree that this Disclosure and Authorization form i n original, faxed, photocopied or
electronic (including electronically signed) form will be valid for any of the above specified records.
Position Title: Department:
Legal Name:
(Last) (First) (MI)
Other Legal Name used:
City: State: ZIP Code:
Contact Phone:
Driver License Number: Driver License State:
Name on
(First) (MI) (Last)
Social Security Number:
Date of Birth:
Applicant Signature:
Date Signed:
Institution: MSU Denver UC Denver CCD Other
Employee 900 Number:
Supervisor: Supervisor Phone #:
Additional Notification:
Entered by HR Rep & Date:
click to sign
click to edit
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
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 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:
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 Board Division of Consumer & Community
Affairs Washington, DC 20551 202-452-3693
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