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DISCLOSURE REGARDING BACKGROUND INVESTIGATION about you from a

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Page 1 of 1
DISCLOSURE REGARDING BACKGROUND INVESTIGATION
_____________________________________ (“the Company”) may obtain information
about you from a third-party consumer reporting agency for employment purposes. Thus,
you may be the subject of a “consumer report” which may include information
about your character, general reputation, personal characteristics, and/or mode of living.
These reports may contain information regarding your credit history, criminal history,
social security verification, motor vehicle records (“driving records”), verification
of your education or employment history, or other background checks.
You have the right, upon written request made within a reasonable time, to
request whether a consumer report has been run about you and to request a
copy of your report. These searches will be conducted by DISA Tustin, 17592 E. 17
th
Street, Suite 300, Tustin, CA 92780, Phone Number 714-731-3084,
www.disa.com.
Applus Technologies
End of Document
Page 1 of 1
DISCLOSURE FOR INVESTIGATIVE CONSUMER REPORT
_____________________________________ (“The Company”) may request an
investigative consumer report about you from a third-party consumer reporting
agency, in connection with your employment or application for employment
(including independent contractor or volunteer assignments, as applicable). An
“investigative consumer report” is a background report that includes information from
personal interviews (except in California, where that term includes background reports
with or without information obtained from personal interviews). The most
common form of an investigative consumer report in connection with your
employment is a reference check through personal interviews with sources such as
your former employers and associates, and other information sources. The
investigative consumer report may contain information concerning your
character, general reputation, personal characteristics, or mode of living. You may
request more information about the nature and scope of an investigative consumer
report, if any, by contacting the Company.
These reports will be obtained by DISA Tustin, 17592 E. 17
th
Street, Suite 300,
Tustin, CA 92780, Phone Number 714-731-3084, www.disa.com.
Applus Technologies
End of Document
Page 1 of 1
ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK
I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING
BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR
CREDIT REPORTING ACT and certify that I have read and understand both of those
documents. I hereby authorize the obtaining of “consumer reports” and/or
“investigative consumer reports” by ____________________________________ (the
"Company") at any time after receipt of this authorization and throughout my
employment, if applicable. To this end, I hereby authorize, without
reservation, any law enforcement agency, administrator, state or federal
agency, institution, school or university (public or private), information service
bureau, employer, or insurance company to furnish all background
information requested by DISA Tustin, 17592 E. 17
th
Street, Suite 300, Tustin, CA
92780, Phone Number 714-731-3084, www.disa.com and/or Company. I agree that a
facsimile (“fax”), electronic or photographic copy of this Authorization shall be as
valid as the original.
New York applicants only: Upon request, you will be informed whether or not a
consumer report was requested by the Company, and if such report was
requested, informed of the name and address of the consumer reporting agency
that furnished the report. You have the right to inspect and receive a copy of any
investigative consumer report requested by the Company by contacting the
consumer reporting agency identified above directly. By signing below, you
acknowledge receipt of Article 23-A of the New York Correction Law
New York City applicants only: By signing this form, you further authorize the
Company to provide you with a copy of your consumer report, the New York City
Fair Chance Act Notice form, and any other documents, to the extent required by
law, at the mailing address and/or email address you provide to the Company.
Washington State applicants only: 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.
Minnesota and Oklahoma applicants only: Please check this box if you would like
to receive a copy of a consumer report if one is obtained by the Company. □
Print Name: __________________________________
Signature: ______________________________________
Drivers License Number:___________________________
SSN: __________________________
Date: ___________________________
State:_______
Date of Birth: _________
Applus Technologies
Deborah LeVerne Patterson
253-35-0299
Electronic Signature: ESO4236614ES4310097
02/07/1965
End of Document
Page 1 of 1
NOTICE REGARDING BACKGROUND CHECKS PER CALIFORNIA LAW
_____________________________________ (the “Company”) intends to obtain information about
you for employment screening purposes from a consumer reporting agency. Thus, you can expect to
be the subject of “investigative consumer reports” obtained for employment purposes. Such reports
may include information about your character, general reputation, personal characteristics and
mode of living. With respect to any investigative consumer report from an investigative consumer
reporting agency (“ICRA”), the Company may investigate the information contained in your
employment application and other background information about you, including but not limited to
obtaining a criminal record report, verifying references, work history, your social security number,
your educational achievements, licensure, and certifications, your driving record, and other
information about you, and interviewing people who are knowledgeable about you. The results of
this report may be used as a factor in making employment decisions. The source of any investigative
consumer report (as that term is defined under California law) will be DISA Tustin, 17592 E. 17
th
Street, Suite 300, Tustin, CA 92780, Phone Number
714-731-3084, www.disa.com. The Company agrees to provide you with a copy of an investigative
consumer report when required to do so under California law.
Under California Civil Code section 1786.22, you are entitled to find out what is in the ICRA’s file on
you with proper identification, as follows:
• In person, by visual inspection of your file during normal business hours and on reasonable
notice. You also may request a copy of the information in person. The ICRA may not charge you more
than the actual copying costs for providing you with a copy of your file.
• A summary of all information contained in the ICRA’s file on you that is required to be
provided by the California Civil Code will be provided to you via telephone, if you have made a
written request, with proper identification, for telephone disclosure, and the toll charge, if any, for
the telephone call is prepaid by or charged directly to you.
• By requesting a copy be sent to a specified addressee by certified mail. ICRAs complying with
requests for certified mailings shall not be liable for disclosures to third parties caused by mishandling
of mail after such mailings leave the ICRAs. “Proper Identification” includes documents such as a valid
driver’s license, social security account number, military identification card, and credit cards. Only if
you cannot identify yourself with such information may the ICRA require additional information
concerning your employment and personal or family history to verify your identity. The ICRA will
provide trained personnel to explain any information furnished to you and will provide a written
explanation of any coded information contained in files maintained on you. This written explanation
will be provided whenever a file is provided to you for visual inspection. You may be accompanied by
one other person of your choosing, who must furnish reasonable identification. An ICRA may require
you to furnish a written statement granting permission to the ICRA to discuss your file in such
person’s presence.
Please check this box if you would like to receive a copy of an investigative consumer report at
no charge if one is obtained by the Company whenever you have a right to receive such a copy under
California law.
Applus Technologies
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Completed 2 December 2021

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