For Release in Word Document: Click Here

                                                             (Please put on your company letterhead)                    
 

                                      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____________

 

 

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