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Oulig Iliffi Tionr G : Lovl20tl

This document is a consent form from Pennsylvania State University for conducting a background check on an applicant. It summarizes that the University may request a consumer report and/or investigative consumer report from HireRight, which may include criminal convictions, public records, driving records, credit reports, and verification of highest degree/professional license. The applicant consents to the background check being performed and understands their rights according to the Fair Credit Reporting Act to receive copies of reports upon request.

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15 views2 pages

Oulig Iliffi Tionr G : Lovl20tl

This document is a consent form from Pennsylvania State University for conducting a background check on an applicant. It summarizes that the University may request a consumer report and/or investigative consumer report from HireRight, which may include criminal convictions, public records, driving records, credit reports, and verification of highest degree/professional license. The applicant consents to the background check being performed and understands their rights according to the Fair Credit Reporting Act to receive copies of reports upon request.

Uploaded by

zawadzahin
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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THg }nNN$YI"VAHTA STATE UH{VSR$ITY A$CLOSI"}RE STATNh{ENT

th* Ilniv*ltlty **ndx*t* raf*r*n*e A* p*rt rf t&e sr*,I *grprxvnl prwuc ef lrr rpp*intxr*ntn *trI oulig ycu t* dircloa* ln wrlsug th* nad heNrgrcxnd xtoe*king, Tne Univ*rrity lqo-_ ary af gJs fntt *nd fiir-un*trrhndlNg af relwrxr r*c& rnd iliffi*tionr*g*

fulkxi*g:
debanne*l by a &der*tr ageney: any fsrm cf Fmfsssisnal mi*E*xs*ct *r senctian$. {1.s., that U?**: ,*st iuiioi ot surrendef; an ndr:rission cr detsrmi*ntisn profos*irn*l you haxe camrnitted research misconduct);

di*il'l#;

*ny nourt' sr discriminetioll ys$ wer*,fo*nd .ts hnv* esmmi'tted by findings ef timirud ro sxry but nsr ndjudientivr b@ ar cdnn$imativy'Gy, ln*to*ing ty- p*on1 *i lb*r*r arnploy*r*; Any folcxy nr hsrgs$dnsnt *r discrimi*ntisu rnsds
Any hcrassrr*nt
lto eon&st' mi*dsmmnu f*r whick ys$ wcrs cnrwiEted nr pled

it*p$ disqurliff you {i'um en sngr6cm** in any ru*h *onduet r$ay nst' -in nnd af m disel*ee s$*h in&rmstis!'' of a$y appcinUrrent X ftJ Uuiv*rxiry" Horxdvar, feilurs mvske en

mir*p*r*nUtiJ;-d- i"

cffer nf ugeuinuo#;; and sv*ilsblc *fi n nscd-ts*knnw bxni* a*ly'


thave nothing to disclose'

iltt$

ia esixeqtion rryith"ths dissl*num' would hc grounds eonfidenti*l uofuu*q*r*nt ernploymcnt' **arr*xion is kcpt

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prsvidc eatpxe*aricn nr npprrrprinre und I havs th* fuliswixlg inform*,ticn. ts *isglose {pl*ase ffich dditionslsheets if necessary)'

AApULLNH

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signature

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ArrI{: F$*"m TS SFFrcs tlf'*HUMAN*TIlqy3ls$' pARK' FA sl']lllslHg* uNrvnx$ITY HACKS&SUIX$ cKncKs' $!& sAlss$ nn"-gLtlstr rgiai; rrlx tl***sxl*ti Cm*tL 4astqrupp#Qg*s*sgs
FLAAss &sruaH

fdl*rrt,srsn

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TITR P'g:Y$I$Y}*Y*NIA $TATg TJT"{IY$RSITY


TF{F'OX.MA?T*}f ANB SAIS$g$IT f,SHfgS}TTJ{S C{}IT$TI${NRAflT} T}{VSSTtrGATIVN CSNSIJMIN,

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{srgnircd befsr* prcc*eding with b*ckgmund ehmhs by Act ts {J"s.{*


Rrquesting Depa*r*rnt

Y1g.e&Anie/ 4^J Nu

e-,\e"^t<V

Wor* Unit Tltis fonn. which y*u sht}uld rcxd uare{i:lly,'has be*n prwvided {s ysu b*eau** $e univ*rsiry rnny rsque$t & e$Rsuffirr repmt undlor investigative eonsumer rcport as those terms are defined by the Fair cretlir jso1i*'pr****enr of Reporri"e background rapor* fur *rnplcyment*r*lafed purposes. Tie universiry will t;q.# iurrn r"pon* sol*ly fur rmplaymx*t-relat*d

a-J';ii.i ;;;r

purpo$*$,

Th* crnsunr repmt nndlor investigrriv* esn$$mar ruport rrill bs ubrain*d krrrr Hirn*.igltt, In*", {*Hire&isht"} losated at ?lss Main street, suite 400, lrvine, cA 9?614. They can be contacea at E00400-z?dl. The i"r"til"ii"" *ught *uf m.iuo* bur nor be iimitcd to a number of f,*utse, rush ils cr{minal eonviclisn.r*eqrd*; public r$urf ${sdsi an$ wh*n applicailn, oepar*nen* uiMnto, Vchi*lc retords, *r*dit repcrt*, and v*ritirsli$n *f highest deryec irapplieable, cunrlnr profe*xi#d ficense **rned. The infonnxtiun will br kapt in sbici ssnfidence uy itirenight and the unive*ity.

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Although uircRight mey $ot br deing c bnclcgro*nd check sn your cr*dit hict*ry, sit:sc such *redi{ r*pcrt i*fnn*atis:r is nst req,rnrtsd rvhtn **ch inftrmstifft has no ernpt*yrn*nt-rainted purp*sa, thi rxler sutlilred in *rs rair *r*dit Rspor{fng Ast, t5 {.t.s,e. $ lsslg{a}, rlx* *pply t* triminEl background cke**s *nd, up*n your r$que$r, I{iraRight sn*r aixsbss; y"- iopy oi it * 13*; y*w fil* ar tNr* tir$s sf thf rEqB63t. Als* cu rcqusst, y$lr ea:r rs**iv* u *spy *fthe " "$ui$:rsry of Your *grr* urd*r the Fair credit R.cporting Act,, prepar*d pur$ue$ is l5 u.s'c'-$ l68lg(c), nnd you have the right r0 rrgueir addltis**I iiscls*ur*s *f th* naturc and **ope of tlre inv*stigation pws$ant ts n p**dvrrs* si adveme aeiion by the university,

have rend ear*fully and snd*srand ttris Is&ns*ti-and, by my signarur* bEra,rv, sorisslrr tc t;e reles$e cf a csn$um&r nndllor in?estig*tivt cqn*urn*r repsrt, ** de&ned absve, to th* {Jniversiry lo riql*ctis$ $i& any lett*r or innic*ticln of iRterest, r*$uine' cr applicatiu* f*r emptoynent. This **nsent fixn in nriginal, fsxe*, efr*;sied or eleptsni, ,*ltt vslid fbr any repsrts that may b's ruq*sst*d bythe univ*rsiry at *ris time or in rh* Sglrsreintivs,,*

,mmrm

f"*, * *y-J*puy**l*"i** p*Jiti*-.

Applicant

L*srNarns

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APl 9ll-[t"-4

! Midd]e
La.AzeL

$*ci*l Securiry $
FEEssnr

Sate of $irth {fnr IB prlrposes llnly}

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City/Star#Iip

Applicant $ignrtrre

I{STICg Tfr CALNFNRXtrA APSLICAI{TS


Under section l?86.?? sf the california civil !cd1, vou rnay in*Bect the {:{e maintained sil yr}u by Hirefi1g}rt. y*u nroy alsc sbtain a copy af this file, upon submitting proper identification and piying rhe cosr of duplication rr*ir**,iy u, njrnish, ofiices in psr$on, dwing ncrmal business hours and on re*ssn&l. n*tlq*; or yg{J may r*criv* a $rml}nry of *e file by mail. ltir*Right has trained p*rsrnncl avsilable tn explain y*ur fil* ts yilu. inctrudlng n*y cad*o infonnatisn. If ycu app*sr in per*on, ycu may be acccmpanied by one other penson.

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Lt F 0R!s*1A, r!{n{$tssfi TA Ari{Ir ff KL*$0*IA ru$tl}EffTg Sff Ly ***ordance wtlh ths lal#s sf calif*rnia, i!{innesota and oklahuma, a resident of sne of those stets$ has the rigirt to receive a free copy of his or her consurnr rcport an&br investigative consumer repart by checiing

I*

tilb*.

I wirh to rsreive a &ee cap)r *f tlre so$sufirer rspsrt snd.lcr investigative coo$u{nqr repfft sn mg ;g*r ir r*quesr*d,

PLEASE RETURN COMPLETED rORM TO OFrtC[ OF HUMAN Rf,SOURCES, ATTI{: BACKGROUND CHSCKS,520 JAMES M. f,LLIOTT BUILDTNG, UNIVSRSITY PARK, PN I6S0z; FAX 8I.I-86g-+iAr;

T*iiL-G**iliC*, ",-

sl.tfi. ?ns$s

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