PLEASE READ CAREFULLY
This document serves solely as a clear and conspicuous written disclosure as required by the Federal Fair Credit Reporting Act set forth in Section 604 (b) to the applicant that a social security, motor vehicle verification, education, previous employment, credit, character, general reputation, personal characteristics, mode of living and a criminal background verification may be obtained for the purpose of this employment application. By the signature below, the Applicant acknowledges that BACKGROUND INFO USA has made this disclosure.
This release and authorization acknowledges that _________________may now, or any time while I am employed, conduct a verification of my education, previous employment/work history, credit history, contact personal references, motor vehicle records, conduct drug testing and to receive any criminal history information pertaining to me which may be in the files of any Federal, State, or Local criminal justice agency, and to verify any other information deemed necessary to fulfill the job requirements. The results of this verification process will be used to determine employment eligibility under __________________employment policies. In the event that information from the report is utilized in whole or in part in making an adverse action decision with regard to your potential employment, before making the adverse decision, we will provide you with a copy of the consumer report and a description in writing of your rights under the law.
I authorize Background Info USA, and any of its agents, to disclose orally and in writing the results of this verification process to the designated authorized representative of______________________.
I have read and understand this release and consent, and I authorize the background verification. I authorize persons, schools, current and former employers, and other organizations and Agencies to provide Background Info USA with all information that may be requested. I hereby release all of the persons and Agencies providing such information from any and all claims and damages connected with their release of any requested information. I agree that any copy of this document is as valid as the original.
I do hereby agree to forever release and discharge___________________, Background Info USA and their associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs and expenses, or any other charge or complaint filed with any Agency arising from retrieving and reporting of information. According to the Federal Fair Credit Reporting Act, I am entitled to know if employment was denied based on information obtained by my prospective employer and to receive a disclosure of the public record information and of the nature and scope of the investigative report.
Applicant Last Name First Name Middle Name
List Other Names Used Date of Birth Social Security Number
Drivers License Number State Drivers License Issued Last name listed on Drivers License
Current Address City/State/Zip
_____
May we contact your current employer
_________________________________________________________________________________________________
Your Email Address
Applicant’s Signature Today’s Date
This Authorization is valid for 90 days from the date of signature.
Return to fax number: 239-494-4347
