BSCMP001 - v07 - 2018-02-13 Page 1 of 1
CONSUMER REPORT AUTHORIZATION
I hereby authorize procurement of consumer report(s) and investigative consumer report(s) by Company. If hired (or contracted), this
authorization shall remain on file and shall serve as ongoing authorization for Company 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 that I have the right to make a request to the consumer reporting agency: Employment Background Investigations, Inc. (“EBI”), P.O.
Box 629, Owings Mills, MD 21117, telephone number (410) 486-0730, upon proper identification, to obtain copies of any reports furnished to
Company by EBI 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 EBI, on Company’s behalf, will provide a complete and accurate disclosure of the nature and scope of the investigation covered by
any investigative consumer report(s). I understand that I can dispute, at any time, any information that is inaccurate in any type of report with EBI.
For complete details pertaining to EBI’s privacy practices, including whether your personal information will be sent outside of the U.S. or its
territories, EBI’s Privacy Policy can be viewed at: http://www.ebiinc.com/privacy-policy.html
.
I acknowledge receipt of the DISCLOSURE FOR CONSUMER REPORTS and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT
REPORTING ACT. I hereby authorize, without reservation, any law enforcement agency, administrator, local, state or federal agency, institution,
school or university (public or private), information service bureau, employer, insurance company or the National Records Center to furnish any and
all background information (including, but not limited to, driving and/or motor vehicle records, transcripts, grades and attendance records,
employment history, salary information and references, workers’ compensation documents, records or reports in Pennsylvania, from the Industrial
Commission of Arizona and in all other states, and drug and alcohol testing results) requested by EBI acting on behalf of Company, and/or Company
itself agree that a facsimile (“fax”) or photographic copy of this Authorization shall be as valid as the original.
STATE SPECIFIC RIGHTS
California, Minnesota and Oklahoma applicants or employees: Please check the box if you would like to receive a copy of your consumer report
if one is obtained by the Company. □
New York applicants or employees: I understand that by signing below, I acknowledge receipt of Article 23-A of the New York Corrections Law.
California applicants or employees: I understand that by signing below, I acknowledge receipt of California Civil Code 1786.22. Pursuant to
Section 1786.22 of the California Civil Code, I understand that I have a right to contact EBI during business hours to obtain all information in EBI’s
file for my review. I may also obtain a copy of such information in person at EBI’s office at the address listed above or by mail. I may also receive a
summary of the file by telephone (if I have previously provided proper identification in writing to EBI). EBI has trained personnel available 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.
Washington applicants or employees: 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.
Company/Employer: ______________________________________________________________________________________________________
Applicant Name: _________________________________________________________________________________________________________
Applicant Signature: __________________________________________________ Date: _____________________________________________
TO BE COMPLETED BY APPLICANT
The Following Information Is True And Correct To The Best Of My Knowledge And Will Be Used For Background Screening Purposes Only.
Please Use an Ink Pen and Print Clearly. Use “UPPER CASE” Letters. One Letter Per Block.
Legal First Name Middle Name
Legal Last Name Suffix
Social Security No. _ _ Date of Birth (mm/dd/yyyy) / /
Current Address Apt.
City State Zip
Main Contact Phone _ _ Personal e-mail Job Location (State)
Driver’s License No. Driver’s License State Gender (M/F)
Other Names Used (Please indicate Y/N if you used this name in school.)
Y N Last Name (1) First Name (1)
Y N Last Name (2) First Name (2)
Y N Last Name (3) First Name (3)
Y N Last Name (4) First Name (4)
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