DISCLOSURE/RELEASE/AUTHORIZATION FORM
1. By this
document (Employers Name) ______________________discloses to you that a
consumer report may be obtained
for employment
purposes as part of the pre-screening background check and at any time
during your employment or
affiliation.
2. This shall
authorize the procurement of a consumer report by a credit reporting
agency or other sources
as part of the
pre-screening background investigation. If accepted, this authorization shall remain on file and shall serve as an ongoing
authorization for the named employer
or its associates or other sources to procure consumer reports at any time
during my
affiliation or employment period.
3. I also
authorize the procurement of an investigative consumer report and
understand that it may contain information
about my
employment and educational background, criminal history, credit, workers
comp claims, mode of
living,
character and personal reputation. I also understand you may make use of
the internet including social networking sites.
I understand
that I have the right to obtain additional disclosure as to the nature and
scope of the investigation
upon written request within a reasonable period
of time and to obtain a copy of the report upon request. This
authorization,
in original or copy form, shall be valid for this and any
future reports or updates that may be requested.
4. In
connection with this request, I authorize all corporations, companies,
former employers, supervisors, credit agencies,
educational
institutions, law enforcement/criminal justice agencies, city, state,
county and federal courts, state motor vehicle
bureaus and
persons to release information they may have about me to the person or
company with which this form has
been filed if required, or their agent.
I further authorize you to secure an investigative consumer
report at any time, and
any number of times, before, during and after my
employment, if in the company's (or its designees) discretion, it has a
legally permissible and legitimate business need for the information requested.
I release
and hold harmless all parties involved from any and all liability for
damages arising from requesting, procuring or
furnishing
the requested information except with respect to a violation of the Act. I
authorize the employer and it's
agent/credit reporting agency and all associated entities and
its clients to receive any criminal history information or credit
report pertaining to me in the files of any state or local criminal justice
agency.
CA, MN, OK RESIDENTS ONLY: As part of a routine
background investigation, we may request a consumer credit report
from a
consumer credit reporting agency or one of its associated companies.
If we do
so and you wish them to send you a
free copy of this consumer credit
report, please check here:_____.
My
signature below also indicates that I have received a
Summary of rights
in accordance with the Fair Credit
Reporting
Act.
Applicant's
Signature______________________________________________________________________
Print
Name_______________________________________________________________________________
Date__________________Other Names
Used__________________________________________________
Social Security Number __________/___________/_________________Date of
Birth_________________
Driver's
License
#__________________________________________________________State___________
Current
Address_______________________________________________City/Town__________________
Zip Code__________________Previous
address________________________________________________
City/Town_________________________________________________State____________Zip____________
