BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION FORM

In the interest of maintaining the safety and security of our customers, employees and property,
___________________________ (the “Company”) will order a “consumer report” (a background report) or “investigative consumer
report" on you in connection with your employment application, and if you are hired, or if you already work for the Company, may order
additional background reports on you for employment purposes.
The background check company, _________________________________ (the "Background Check Company"), will prepare the
background report for the Company. The Background Check Company is located at ___________________________, and can be
reached by phone at ____________________ or at their Internet Web site address _____________________________.
The background report may contain information concerning your character, general reputation, personal characteristics, mode of living,
and credit standing. The types of information that may be ordered include but are not limited to: Social Security number verification;
criminal, public, educational and, as appropriate, driving records checks; verification of prior employment; reference, licensing and
certification checks; credit reports; drug testing results; and, if applicable, worker’s compensation injuries. Workers’ compensation
information will only be requested in compliance with federal Americans with Disabilities Act and/or any other applicable federal, state or
local laws and only after a conditional job offer is made. Credit history will only be requested when permitted by law and where such
information is substantially related to the duties and responsibilities of the position for which you are applying. The information may be
obtained from private and public record sources, including personal interviews with your associates, friends, and neighbors. (An
“investigative consumer report” is a background report that includes information from such personal interviews, except in California where
that term means any background report that is not a credit report.) The nature and scope of the most common form of investigative
consumer report is an investigation into your education and/or employment history conducted by the Background Check Company or
another outside organization.
You may request more information about the nature and scope of an investigative consumer report, if any, by telephoning the Company at
________________________. A summary of your rights under the Fair Credit Reporting Act is also being provided to you with this form.
The Fair Credit Reporting Act gives you specific rights in dealing with consumer reporting agencies. You will find these rights summarized
on A Summary of Your Rights Under the Fair Credit Reporting Act and A Summary of Your Rights Under the Provisions of California Civil
Code Section 1786.22 for California residents..
STATE LAW NOTICES
If you live or work for the Company in the states listed below, please note the following:
CALIFORNIA: You may view the file that the Background Check Company has for you, and order a copy of the file, upon submitting
proper identification and paying copying costs, by coming to their offices, during normal business hours and on reasonable notice, or by
certified mail or mail. You may also ask for a file-summary by telephone. The Background Check Company can answer questions
about information in your file, including any coded information. If you come in person, another person can come with you, so long as that
person can show proper identification.
MAINE: If you ask us, you have the right to know whether the Company ordered an investigative consumer report on you. You
may request the name, address, and telephone number of the nearest office for the Background Check Company. You will get this
information within 5 business days of our receipt of your request. You have the right to ask the Background Check Company for a free
copy of the report.
MARYLAND: If the Company obtains credit history information on you, it will be used to evaluate whether you would present an
unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.
MASSACHUSETTS/NEW JERSEY: If you submit a request to us in writing, you have the right to know whether the Company ordered an
investigative consumer report from the Background Check Company. You may inspect and order a free copy of the report by
contacting the Background Check Company.
MINNESOTA: If you submit a request to us in writing, you have the right to get from the Company a complete and accurate disclosure of
the nature and scope of the consumer report or investigative consumer report ordered, if any.
NEW YORK: If you submit a request to us in writing, you have the right to know whether the Company ordered a consumer report or an
investigative consumer report from the Background Check Company, and you will be provided with the name and address of the
Background Check Company. You may inspect and order a free copy of the reports by contacting the Background Check Company.
By signing below, you certify you have received a copy of Article 23A of the New York Correction Law is being provided with this form.
OREGON: If the Company obtains credit history information on you, it will be used to evaluate whether you would present an
unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.
WASHINGTON STATE: If you submit a request to us in writing, you have the right to get from the Company a complete and accurate
disclosure of the nature and scope of the investigative consumer report we ordered, if any. You also have the right to ask the
Background Check Company for a written summary of your rights under the Washington Fair Credit Reporting Act. If the Company
obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be used to evaluate whether you would
present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.

Page 1 of 7 Form Made Fillable by eForms

After carefully reading this Background Check Disclosure and Authorization form, I authorize the Company to order my
background report, including investigative consumer reports. I understand that the Company may rely on this authorization
to order additional background reports, including investigative consumer reports, during my employment without asking me
for my authorization again as allowed by law.

I also authorize the following agencies and entities to disclose to the Background Check Company and its agents all
information about or concerning me, including but not limited to: my past or present employers; learning
institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal,
state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; if applicable,
worker’s compensation injuries; all other private and public sector repositories of information; and any other person,
organization, or agency with any information about or concerning me. Workers’ compensation information will only be
requested in compliance with federal Americans with Disabilities Act and/or any other applicable federal, state or local
laws and only after a conditional job offer is made. The information that can be disclosed to the Background Check
Company and its agents includes, but is not limited to, information concerning my employment history, earnings history,
education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses and
substance abuse testing.

I agree the Company may rely on this authorization to order background reports, including investigative consumer
reports, from companies other than the Background Check Company without asking me for my authorization again as
allowed by law. I also agree that a copy of this form is valid like the signed original. I certify that all of the personal
information I provided is true and correct.

Last Name __________________________________ First ________________________ Middle ____________________

Maiden/Other Names _______________________________________________ Years Used _______________________

If you live or work for the Company in California, Minnesota or Oklahoma: Check this box if you would like a free
copy of your background check report: ☐

______________________________________________________________ _____/_______/________
Signature Date: (Month/Day/Year)

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 BACKGROUND CHECK INFORMATION:

The information requested below is collected solely for the purpose of aiding the Company in running a background check
in connection with your application for employment. The employer is requesting that you provide this information to assist
in conducting a thorough background check.

For residents of, or for jobs located in Utah, please do NOT provide your date of birth, social security number or driver’s
license number until instructed to do so by the Company.

First Name _______________________Middle Name __________________Last Name_________________________

Date of Birth ____/____/____ (Month/Day/Year)

Social Security Number ____________________________________________________

Driver’s License Number ______________________________ State Issuing License_________________________

Enter Any Other Names Used (including maiden names):

Addresses Within The Past Seven Years (use a separate sheet as needed)

Present Street Address ___________________________________________________________

City/State/ZIP ___________________________________________________________________________

Prior Street Address _________________________________________________________________

From _____/_______/______ (Month/Day/Year) To _____/_______/______ (Month/Day/Year)

City/State/ZIP __________________________________________________________________________

Prior Street Address _________________________________________________________________

From _____/_______/______ (Month/Day/Year) To _____/_______/______ (Month/Day/Year)

City/State/ZIP __________________________________________________________________________

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 Para informacion en espanol, visite • You have the right to dispute incomplete or inaccurate
www.consumerfinance.gov/learnmore o escribe a la information. If you identify information in your file that is
Consumer Financial Protection Bureau, 1700 G Street N.W., incomplete or inaccurate, and report it to the consumer
Washington, DC 20552. reporting agency, the agency must investigate unless your
dispute is frivolous. See
A Summary of Your Rights Under the Fair Credit Reporting www.consumerfinance.gov/learnmore for an explanation of
Act dispute procedures.
• Consumer reporting agencies must correct or delete
The federal Fair Credit Reporting Act (FCRA) promotes the inaccurate, incomplete, or unverifiable information.
accuracy, fairness, and privacy of information in the files of Inaccurate, incomplete or unverifiable information must be
consumer reporting agencies. There are many types of consumer removed or corrected, usually within 30 days. However, a
reporting agencies, including credit bureaus and specialty consumer reporting agency may continue to report
agencies (such as agencies that sell information about check information it has verified as accurate.
writing histories, medical records, and rental history records). • Consumer reporting agencies may not report outdated
Here is a summary of your major rights under the FCRA. For negative information. In most cases, a consumer reporting
more information, including information about additional agency may not report negative information that is more than
rights, go to www.consumerfinance.gov/learnmore or write seven years old, or bankruptcies that are more than 10 years
to: Consumer Financial Protection Bureau, 1700 G Street old.
N.W., Washington, DC 20552. • Access to your file is limited. A consumer reporting agency
may provide information about you only to people with a valid
• You must be told if information in your file has been need -- usually to consider an application with a creditor,
used against you. Anyone who uses a credit report or insurer, employer, landlord, or other business. The FCRA
another type of consumer report to deny your application for specifies those with a valid need for access.
credit, insurance, or employment – or to take another • You must give your consent for reports to be provided to
adverse action against you – must tell you, and must give employers. A consumer reporting agency may not give out
you the name, address, and phone number of the agency information about you to your employer, or a potential
that provided the information. employer, without your written consent given to the
• You have the right to know what is in your file. You may employer. Written consent generally is not required in the
request and obtain all the information about you in the files of trucking industry. For more information, go to
a consumer reporting agency (your “file disclosure”). You will www.consumerfinance.gov/learnmore.
be required to provide proper identification, which may • You may limit “prescreened” offers of credit and
include your Social Security number. In many cases, the insurance you get based on information in your credit
disclosure will be free. You are entitled to a free file report. Unsolicited “prescreened” offers for credit and
disclosure if: insurance must include a toll-free phone number you can call
. a person has taken adverse action against you because if you choose to remove your name and address from the
of information in your credit report; lists these offers are based on. You may opt-out with the
. you are the victim of identity theft and place a fraud alert nationwide credit bureaus at 1-888-567-8688.
in your file; • You may seek damages from violators. If a consumer
. your file contains inaccurate information as a result of reporting agency, or, in some cases, a user of consumer
fraud; reports or a furnisher of information to a consumer reporting
. you are on public assistance; agency violates the FCRA, you may be able to sue in state or
. you are unemployed but expect to apply for employment federal court.
within 60 days. • Identity theft victims and active duty military personnel
In addition, all consumers are entitled to one free disclosure every have additional rights. For more information, visit
12 months upon request from each nationwide credit bureau and www.consumerfinance.gov/learnmore.
from nationwide specialty consumer reporting agencies. See
www.consumerfinance.gov/learnmore for additional information. States may enforce the FCRA, and many states have their
• You have the right to ask for a credit score. Credit scores own consumer reporting laws. In some cases, you may
are numerical summaries of your credit-worthiness based on have more rights under state law. For more information,
information from credit bureaus. You may request a credit contact your state or local protection agency or your state
score from consumer reporting agencies that create scores Attorney General. For information about your federal
or distribute scores used in residential real property loans, rights, contact:
but you will have to pay for it. In some mortgage
transactions, you will receive credit score information for free
from the mortgage lender.

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 TYPE OF BUSINESS: CONTACT:
1.a. Banks, savings associations, and credit unions with total a. Consumer Financial Protection Bureau
assets of over $10 billion and their affiliates. 1700 G Street, N.W.
Washington, DC 20552
b. Such affiliates that are not banks, savings associations, or b. Federal Trade Commission: Consumer Response Center –
credit unions also should list, in addition to the CFPB: FCRA
Washington, DC 20580
(877) 382-4357
2. To the extent not included in item 1 above: a. Office of the Comptroller of the Currency
Customer Assistance Group
a. National banks, federal savings associations, and federal 1301 McKinney Street, Suite 3450
branches and federal agencies of foreign banks Houston, TX 77010-9050
b. State member banks, branches and agencies of foreign b. Federal Reserve Consumer Help Center
banks (other than federal branches, federal agencies, and P.O. Box 1200
Insured State Branches of Foreign Banks), commercial Minneapolis, MN 55480
lending companies owned or controlled by foreign banks, c. FDIC Consumer Response Center
and organizations operating under section 25 or 25A of the 1100 Walnut Street, Box # 11
Federal Reserve Act Kansas City, MO 64106
c. Nonmember Insured Banks, Insured State Branches of d. National Credit Union Administration
Foreign Banks, and insured state savings associations Office of Consumer Protection (OCP)
d. Federal Credit Unions Division of Consumer Compliance and Outreach (DCCO)
1775 Duke Street
Alexandria, VA 22314
3. Air carriers Asst. General Counsel for Aviation Enforcement & Proceedings
Aviation Consumer Protection Division
Department of Transportation
1200 New Jersey Avenue, S.E.
Washington, DC 20590
4. Creditors Subject to the Surface Transportation Board Office of Proceedings, Surface Transportation Board
Department of Transportation
395 E Street, S.W.
Washington, DC 20423
5. Creditors Subject to the Packers and Stockyards Act, 1921 Nearest Packers and Stockyards Administration area supervisor
6. Small Business Investment Companies Associate Deputy Administrator for Capital Access
United States Small Business Administration
409 Third Street, SW, 8th Floor
Washington, DC 20416
7. Brokers and Dealers Securities and Exchange Commission
100 F Street, N.E.
Washington, DC 20549
8. Federal Land Banks, Federal Land Bank Associations, Farm Credit Administration
Federal Intermediate Credit Banks, and Production Credit 1501 Farm Credit Drive
Associations McLean, VA 22102-5090

9. Retailers, Finance Companies, and All Other Creditors Not FTC Regional Office for region in which the creditor operates or
Listed Above Federal Trade Commission: Consumer Response Center –
FCRA
Washington, DC 20580
(877) 382-4357

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 A Summary of Your Rights
Under the Provisions of California Civil Code Section 1786.22

The Investigative Consumer Reporting Agencies Act (ICRA) is designed to promote accuracy, fairness,
and privacy of information in the files of every "consumer reporting agency" (CRA). You can find the
complete text of the ICRA, at the California Privacy Protection web site
(http://www.privacy.ca.gov/icraa.htm). The ICRA gives you specific rights, as outlined below. You may
have additional rights under federal law. You may contact a state or local consumer protection agency or
a state attorney general to learn those rights.

(a) An investigative consumer reporting agency shall supply files and information required under Section
1786.10 during normal business hours and on reasonable notice.

(b) Files maintained on a consumer shall be made available for the consumer's visual inspection, as
follows:
(1) In person, if he appears in person and furnishes proper identification. A copy of his file shall also be
available to the consumer for a fee not to exceed the actual costs of duplication services provided.
(2) By certified mail, if he makes a written request, with proper identification, for copies to be sent to a
specified addressee. Investigative consumer reporting agencies complying with requests for certified
mailings under this section shall not be liable for disclosures to third parties caused by mishandling of
mail after such mailings leave the investigative consumer reporting agencies.
(3) A summary of all information contained in files on a consumer and required to be provided by Section
1786.10 shall be provided by telephone, if the consumer has made a written request, with proper
identification for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or
charged directly to the consumer.

(c) The term "proper identification" as used in subdivision (b) shall mean that information generally
deemed   sufficient   to   identify   a   person.   Such   information   includes   documents   such   as   a   valid   driver’s  
license, social security account number, military identification card, and credit cards. Only if the consumer
is unable to reasonably identify himself with the information described above, may an investigative
consumer reporting agency require additional information concerning the consumer's employment and
personal or family history in order to verify his identity.

(d) The investigative consumer reporting agency shall provide trained personnel to explain to the
consumer any information furnished him pursuant to Section 1786.10.

(e) The investigative consumer reporting agency shall provide a written explanation of any coded
information contained in files maintained on a consumer. This written explanation shall be distributed
whenever a file is provided to a consumer for visual inspection as required under Section 1786.22.

(f) The consumer shall be permitted to be accompanied by one other person of his choosing, who shall
furnish reasonable identification. An investigative consumer reporting agency may require the consumer
to furnish a written statement granting permission to the consumer reporting agency to discuss the
consumer's file in such person's presence.

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 NEW YORK CORRECTION LAW
ARTICLE 23-A
LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY
CONVICTED OF ONE OR MORE CRIMINAL OFFENSES
Section 750. Definitions.
751. Applicability.
752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited.
753. Factors to be considered concerning a previous criminal conviction; presumption.
754. Written statement upon denial of license or employment.
755. Enforcement.
§750. Definitions. For the purposes of this article, the following terms shall have the following meanings:
(1) "Public agency" means the state or any local subdivision thereof, or any state or local department, agency, board or commission.
(2) "Private employer" means any person, company, corporation, labor organization or association which employs ten or more
persons.
(3) "Direct relationship" means that the nature of criminal conduct for which the person was convicted has a direct bearing on his
fitness or ability to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in
question.
(4) "License" means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions
or instrumentalities as a condition for the lawful practice of any occupation, employment, trade, vocation, business, or profession.
Provided, however, that "license" shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire
any explosive, pistol, handgun, rifle, shotgun, or other firearm.
(5) "Employment" means any occupation, vocation or employment, or any form of vocational or educational training. Provided,
however, that "employment" shall not, for the purposes of this article, include membership in any law enforcement agency.
§751. Applicability. The provisions of this article shall apply to any application by any person for a license or employment at any public or
private employer, who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any
license or employment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdiction
preceded such employment or granting of a license, except where a mandatory forfeiture, disability or bar to employment is imposed by
law, and has not been removed by an executive pardon, certificate of relief from disabilities or certificate of good conduct. Nothing in this
article shall be construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with an
application for employment made by a prospective employee or previously made by a current employee.
§752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited. No application for
any license or employment, and no employment or license held by an individual, to which the provisions of this article are applicable, shall
be denied or acted upon adversely by reason of the individual's having been previously convicted of one or more criminal offenses, or by
reason of a finding of lack of "good moral character" when such finding is based upon the fact that the individual has previously been
convicted of one or more criminal offenses, unless:
(1) There is a direct relationship between one or more of the previous criminal offenses and the specific license or employment
sought or held by the individual; or
(2) the issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk
to property or to the safety or welfare of specific individuals or the general public.
§753. Factors to be considered concerning a previous criminal conviction; presumption.
1. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall
consider the following factors:
(a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons
previously convicted of one or more criminal offenses. (b) The specific duties and responsibilities necessarily related to the
license or employment sought or held by the person. (c) The bearing, if any, the criminal offense or offenses for which the
person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities.
(d) The time which has elapsed since the occurrence of the criminal offense or offenses.
(e) The age of the person at the time of occurrence of the criminal offense or offenses.
(f) The seriousness of the offense or offenses.
(g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct.
(h) The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of
specific individuals or the general public.
2. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall
also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which
certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein.
§754. Written statement upon denial of license or employment. At the request of any person previously convicted of one or more
criminal offenses who has been denied a license or employment, a public agency or private employer shall provide, within thirty days of a
request, a
written statement setting forth the reasons for such denial.
§755. Enforcement.
1. In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to
article seventy-eight of the civil practice law and rules.
2. In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights
pursuant to the powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city
commission on human rights.

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