Fillable Disclosure And Authorization (Winthrop University)

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Disclosure And Authorization (Winthrop University)

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Candidate Initials________ Page 1 of 2
WINTHROP UNIVERSITY
OFFICE OF HUMAN RESOURCES, EMPLOYEE DIVERSITY & WELLNESS
Winthrop University Background Check Disclosure and Authorization Form
[For Employment or Volunteer Purposes]
The applicant for employment acknowledges that Winthrop University may now, or at any time while employed, verify information within
the application, resume or contract for employment. Winthrop University uses S2Verify, LLC as an agent to perform background
investigations. In the event that information from the report is utilized in whole or in part in making an adverse decision, before making
the adverse decision, we will provide to you a copy of the consumer report and a description in writing of your rights under the Fair
Credit Reporting Act, 15 U.S.C. § 1681 et seq.
Please be advised that we may also obtain an investigative consumer report including information as to your character, general
reputation, personal characteristics, and mode of living. This information may be obtained by contacting your present and previous
employers or references supplied by you. Please be advised that you have the right to request, in writing, within a reasonable time, that
we make a complete and accurate disclosure of the nature and scope of the investigation requested.
Additional information concerning the Fair Credit Reporting Act, 15 U.S.C. § 1681 et seq., is available at the Federal Trade
Commission’s web site (http://www.ftc.gov). 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.
By signing below, I hereby authorize all entities having information about me, including present and former employers,
personal references, criminal justice agencies, departments of motor vehicles, schools, licensing agencies, and credit
reporting agencies, to release such information to Winthrop University. I agree that a fax or photocopy of this authorization
and my signature shall be accepted with the same authority as the original. I acknowledge and agree that this Background
Check Disclosure and Authorization Form shall remain valid and in effect during the term of my contract.
For Maine Applicants Only
Upon request, you will be informed whether or not an investigative consumer report was requested, and if such a
report was requested, the name and address of the consumer reporting agency furnishing the report. You may request
and receive from us, within 5 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 reports.
For New York Applicants Only
You have the right, upon written 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.
For Washington Applicants Only
If we request an investigative consumer report, you have the right, upon written request made within a reasonable
period of time, to receive from us a complete and accurate disclosure of the nature and scope of the investigation. You
have the right to request from the consumer reporting agency a summary of your rights and remedies under state law.
For California*, Minnesota, and Oklahoma Applicants Only
A consumer credit report will be obtained through S2Verify LLC, P.O. Box 2597, Roswell, GA 30077; Telephone: (770)
649-8282; Email: compliance@s2verify.com
.
If a consumer credit report is obtained, I understand that I am entitled to receive a copy. I have indicated below
whether I would like a copy: Yes______ No _
Initials Initials
If an investigative consumer report and/or consumer report is processed, I understand that I am entitled to receive a
copy. I have indicated below whether I would like a copy: Yes ______ No______
Initials Initials
*California Applicants: If you chose to receive a copy of the consumer report, it will be sent within three (3) days of
the employer receiving a copy of the consumer report and you will receive a copy of the investigative consumer report
within seven (7) days of the employer’s receipt of the report (unless you elected not to get a copy of the report).
S2Verify’s privacy practices with respect to the preparation and processing of investigative consumer reports may be
found at www.S2verify.com (link at bottom of page entitled, “Legal/Privacy”).
Page 2 of 2
The following information is required to complete the background investigation (please print):
FIRST NAME
MIDDLE NAME
LAST NAME
OTHER NAMES USED (INCLUDING MAIDEN NAME)
SOCIAL SECURITY NUMBER
DATE OF BIRTH (MM/DD/YYYY)
GENDER
DRIVER’S LICENSE NUMBER
STATE LICENSED IN
EXPIRATION DATE (MM/DD/YYYY)
CURRENT AND PREVIOUS ADDRESSES
CURRENT STREET ADDRESS (NO P.O. BOXES)
CITY
STATE
ZIP CODE
PREVIOUS STREET ADDRESS (NO P.O. BOXES)
CITY
STATE
ZIP CODE
PREVIOUS STREET ADDRESS (NO P.O. BOXES)
CITY
STATE
ZIP CODE
Have you ever been convicted of a crime other than a minor traffic violation?
Please check one: No Yes
(A criminal conviction does not necessarily disqualify an applicant for employment consideration. Making
untrue statements or otherwise failing to report criminal conviction(s) will disqualify an applicant for
consideration for this position for falsification of an application.)
If Yes, list the date, location (county and state), and offense for all misdemeanor and felony convictions
regardless of how minor or how long ago they occurred. Attach additional pages if needed.
DATE OF CONVICTION
LOCATION (COUNTY/STATE)
OFFENSE
DATE OF CONVICTION
LOCATION (COUNTY/STATE)
OFFENSE
DATE OF CONVICTION
LOCATION (COUNTY/STATE)
OFFENSE
SIGNATURE:
DATE
If under the age of 18, parent/guardian signature required:
SIGNATURE – PARENT/GUARDIAN PRINT NAME – PARENT/GUARDIAN DATE
TO BE COMPLETED BY DEPARTMENT CONTACT – THIS PERSON WILL BE NOTIFIED OF RESULTS
NAME
DEPARTMENT NAME
EMAIL ADDRESS
SELECT BACKGROUND CHECK TYPE:
Staff Faculty Temp Student Volunteer
WINTHROP UNIVERSITY
OFFICE OF HUMAN RESOURCES, EMPLOYEE DIVERSITY & WELLNESS
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Disclosure And Authorization (Winthrop University)

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Completed 18 July 2020

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