JUSTIFACTS CREDENTIAL VERIFICATION, INC.
8085 Saltsburg Road, Suite 100, Pittsburgh, PA 15239 PHONE: (800) 356-6885 ~ FAX: (412) 798-4799
www.justifacts.com
Notification and Authorization to Conduct Employment Background Investigation
I hereby authorize Justifacts Credential Verification, Inc, an Agent for Clarion University to investigate my background to
determine any and all information of concern to my record, whether same is of record or not, and I release employers and persons named in my
application from all liability for any damages on account of his/her furnishing said information. I understand that this form indicates that a
background search will be conducted and that this is my notification of that intent. I understand that the purpose of this background investigation is
to determine my suitability for employment and may elicit information on my character, general reputation, personal characteristics and mode of
living.
Additionally, you are hereby authorized to make any investigation of my personal history, educational background, military record, motor
vehicle records, criminal records, workers compensation and credit history through an investigative or credit agency or bureau of your choice. I
authorize the release of this information by the appropriate agencies to the investigating service. This authorization, in original or copy form, shall
be valid for this initial report only.
PLEASE PRINT CLEARLY
FULL NAME:
OTHER NAMES USED/MAIDEN NAME/DATES:
CURRENT
ADDRESS:
PHONE:
LIST ALL ADDRESSES FOR PAST 7 YEARS:
Dates:
Dates:
Dates:
EMAIL ADDRESS: _______________________________________________________________________________________________
SOCIAL SECURITY #
DATE OF BIRTH:
DRIVER’S LICENSE #
STATE ISSUED:
*** MAY WE CONTACT YOUR CURRENT EMPLOYER? YES _______ NO
*** HAVE YOU EVER BEEN CONVICTED OF A CRIME? YES _______ NO
Notice to California Applicants
(You may omit minor traffic offenses, any convictions which have been sealed, expunged or statutorily eradicated, convictions more than two years old for the
following marijuana related offenses: HS11357b&c, HS11360c, HS11364, HS11365, HS11550, and misdemeanors for which probation was completed and the case
was judicially dismissed)
If yes, please explain:
Note: No applicant will be denied employment solely on the grounds of conviction of a crime. The nature of the offense, the date of the offense, the
surrounding circumstances and the relevance of the offense to the position will be considered.
SIGNATURE:
DATE:
Under Section 1786.22 of the California Civil Code, you have the right to request from Justifacts, upon proper identification, the nature and substance of all information in its files on you,
including the sources of information, and the recipients of any reports on you which Justifacts has previously furnished within the two-year period preceding your request. You may view the
file maintained on you by Justifacts during normal business hours. You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services.
Upon making a written request, you may receive a summary of your report via telephone
.
□ California, Minnesota & Oklahoma Applicants Only: Please check this box if you would like a copy of the background check mailed to
you. Minnesota and Oklahoma applicants will receive a copy direct from Justifacts or its designee. California applicants may receive a copy from
either the prospective employer or Justifacts.
NOTICE: Under federal law, you have the right to request disclosure of the nature and scope of our investigation by providing us with a written
request within 60 days of our background investigation.
Subscriber certifies that consumer credit information, consumer reports, as defined by the Fair Credit Reporting Act, 15 U.S.C. 1681 at seq. (“FCRA”), will be ordered
only when intended to be used as a factor in establishing a consumer’s eligibility for employment and that consumer credit information will be used for no other
purposes. It is recognized and understood that the FCRA provides that anyone “who knowingly and willfully obtains information on a consumer from a consumer
reporting agency” (such as Justifacts) “under false pretenses shall be fines not more than $5,000 or imprisoned not more than two years or both.”
REV. 3/05
