Warning: This is a preview of the iForm only. You cannot submit answers.
BACKGROUND INFORMATION -
DISCLOSURE AND AUTHORIZATION FORM
I. DISCLOSURE REGARDING BACKGROUND INVESTIGATION
IMPORTANT — PLEASE READ CAREFULLY BEFORE SIGNING
In connection with your employment application and for other employment purposes, including but no limited to promotion, assignment, reassignment, or discipline,  (the "Company") may seek background information about you from a consumer reporting agency. This information may be in the form of both consumer reports and investigative consumer reports (each, a "Report" and collectively, "Reports").

To the extent permitted by law, these Reports may be obtained at any time after receipt of your authorization, including any time during the period of your employment or contract period, if the Company hires you.

Consumer reports include any written, oral, or other communication of information by a consumer reporting agency bearing on your credit standing, character, general reputation, and other personal characteristics that is expected to be used for employment purposes. Consumer reports may include credit reports, criminal records, social security verification, employment and education verification, and driving records, among other resources.

Investigative consumer reports include similar information as consumer reports, which are obtained through personal interviews with those who are acquainted with you or who may have knowledge of any relevant information about you.

, or another consumer reporting agency, will obtain the reports for the Company.  is located at , and can be reached at .

You have the right to request information from the Company about the nature and scope of any Report(s) by contacting the Company in writing, within a reasonable period of time after receipt of this disclosure

A summary of your rights under the Fair Credit Reporting Act is also being provided to you.
II. AUTHORIZATION TO OBTAIN REPORTS
I acknowledge that I have received and read the Disclosure Regarding Background Investigation, and this authorization. I have received a copy of the "Summary of Your Rights Under the Fair Credit Reporting Act" and any applicable state or local notices of rights provided with these documents. I certify that I have had the opportunity to review my rights, and understand the documents I have received.

I hereby authorize the Company or its authorized agents, for employment purposes, to obtain or prepare Report(s) at any time after receipt of this authorization, including, if hired, any time during the period I may be employed by the Company.

I hereby authorize any law enforcement agency, federal, state, and local agencies and courts, credit bureaus, information bureaus, current and former employers, public and private schools, institutions and universities, financial institutions, licensing agencies, governmental agencies, the military, and other individuals and entities to provide any and all information that is requested by , other consumer reporting agencies, or the Company.

I agree that this form in original, faxed, photocopied or electronic (including an electronically signed) form will be valid for any background investigation that may be requested by or on behalf of the Company.

By my signature below, I certify that the information provided on the attached forms is true and accurate. I understand that, to the extent allowed by law, any information that I provide in an employment application or that I otherwise disclose during my employment may be used to obtain Reports.
Signature of Acknowledgement and Authorization:
First Name
Middle Name
Last Name

Signature
(checking the checkbox above is equivalent to a handwritten signature)

 

TO BE COMPLETED BY APPLICANT
The following information is requested in order to process your background investigation. It will be used for background screening purposes only.
First Name
Middle Name
Last Name
Other Known Names Or Other Names Used
First Name
Last Name
From
To
ADDRESS INFORMATION
Current Addresses
Type

Current Address
Current Address 2
City
Country

State
Zip
Previous Address of Residence (past seven years)
Address
City
Country
State
Zip
From (mm/yy)
To (mm/yy)
 
Phone Numbers
Type
 
Number
Extension
Email
 
Date of Birth (mm/dd/yyyy)
Social Security No.
-
-
Any changes will overwrite saved masked data
Driver's License No.
State