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DISCLOSURE As part of the employment process, _______ (the "Company"), will obtain a consumer report (known as an investigative consumer report in California), which I understand may include information regarding my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. AUTHORIZATION During the application process and at any time during the tenure of my employment with the Company, I hereby authorize ChoicePoint Services Inc., on behalf of The Company to procure a consumer report (known as an investigative consumer report in California) which I understand may include information regarding my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. This report may be compiled with information from credit bureaus, courts record repositories, departments of motor vehicles, past or present employers and educational institutions, governmental occupational licensing or registration entities, business or personal references, and any other source required to verify information that I have voluntarily supplied. I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification, to the extent such investigation includes information bearing on my character, general reputation, personal characteristics or mode of living. __________________________________ ______________________ Applicant/Employee Name and Signature Date ________-_____-__________ ________________________ Social Security Number * Date of Birth * * Optional MN & Oklahoma Residents please note: In connection with your application for employment, your consumer report may be obtained and reviewed. Under Minnesota and Oklahoma law, you have a right to receive a free copy of your consumer report by checking the appropriate box below. ___ YES, I am a Minnesota resident and would like a free copy of my consumer report. ___ YES, I am an Oklahoma resident and would like a free copy of my consumer report. CA Residents please note: In connection with your application for employment, your credit report will be obtained and reviewed. Under CA law, you have a right to receive a free copy of your credit report by checking the appropriate box below. Your credit report will be mailed to you by the credit bureau. In the alternative, you may elect to receive the entire investigative consumer report, which will include your credit report. ___ YES, I am a California resident and would like a free copy of my credit report; or ___ YES, I am a California resident and would like a free copy of my investigative consumer report. Printed Name ________________________________ Street Address________________________________ City, State, Zip _______________________________ FOR OFFICE USE ONLY BACKGROUND VERIFICATION DISCLOSURE As part of the employment process, ________________________________ , ("The Company"), will obtain an investigative consumer report. The investigative consumer report may include information regarding your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics or mode of living. The following Consumer Reporting Agency will prepare the report: ChoicePoint Services Inc. California Notice: You have the right under Section 1786.22 of the California Civil Code to contact ChoicePoint during normal business hours to obtain your file for your review. You may obtain such information as follows: 1. In person at ChoicePoint’s office at the address listed above. You will need to furnish proper identification prior to receiving your file. You may have someone accompany you and should inform such person that they will also have to present reasonable identification. If you want ChoicePoint to disclose to or discuss your information with this third party, you may be required to provide a written statement granting ChoicePoint permission to do so. 2. By certified mail, if you make a written request (and provide proper identification) to have your file sent to a specified addressee. 3. By telephone, if you have previously made a written request and provided proper identification. ChoicePoint has trained personnel to explain any information that is furnished to you and to explain any information that is coded. |