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DISCLOSURE AND"AUTHORIZATION"[IMPORTANT --!PLEASE !READ !CAREF U L LY !B E F O R E !SIG NING !AUTHORIZATION]
DISCLOSURE REGARDING!BACKGROUND!INVESTIGATION
(“the Company”)!may obtain information a bo u t!you for employment purposes from a!third party
consumer reporting agency. Thus, you may!be the sub ject of a “consumer report” and/or an “investigative consumer report” w hich may!include
information about your character, general reputation, personal characteristics, and/or mode of living, and!which!can!involve personal interviews
with sources such as your neighbors, friends, or associates. These reports may contain information regarding your credit history, criminal!history,
social security!number validation, motor vehicle records!(“driving records”), verification of your education or employment history, or other
background!checks. Credit history w ill only be requested!where such!information!is substantially related to the!duties and responsibilities of the!
position!for which!you!are applying. You!have the right, upon!written!request made within!a reasonable time, to!request w hether a consumer
report!has been requested an d compiled about!you, and d isclosu re of!the!nature!and scope!of any investigative!consumer report and to request a!
copy!of your report. Please be advised that the nature and scope of the most common form o f investigative consu m er report obtained with regard
to applicants fo r!em plo ym en t!is an investigation into your ed ucation and/or employment history!conducted by!Validity!Screening Solutions, PO Box
860443, Sh awnee, KS!66286-0443, 866.915.0792, www.validityscreening.com
, or another outside organization. The scope of this notice and!
authorization is all-encompassing, however, allowing!the!Company to obtain from any outside!organization all manner of consumer reports and
investigative consumer reports now and th ro u g ho u t the course of your employmen t to the e xte n t permitted by law.! As a result, you should
carefully!consider whether to exercise your right to request disclosure of the nature and scope of any!investigative consumer report.
New York and Maine"applicants or employees only:!!You !have!the!right!to inspect!and receive!a copy!of!any!investigative!consumer report!requested by!
by contacting the consumer reporting agency identified!above directly. You!may also!contact the Company to!request the name, address
and telephone!number of the!nearest unit of the!consumer reporting!agency!designated to handle!inquiries, which the!Company!shall provide!within 5!days.
New York applicants or employees only: !Upon !request, !you !will!be !informed !wh et h er!o r!n ot a !consumer!report !was !re q ue st ed !b y ,!
and if such report was!requested, informed of the!name!and address!of the!consumer reporting!agency that furnished the!report. By signing!below, you also
acknowledge!receipt of Article!23-A!of the New York Correction Law.
Oregon applicants or employees only: !Information !describing !your!rights !under!federa l!an d !Oregon !law !regarding !consumer!identity !theft !protection, !the !storage
and disposal of your credit information, and remedies!available!should you suspect or find that the!Company has!not maintained secured records!is!available!to you
upon!request.
Washington State applicants or employees only: You!also!have the right to!request from the consumer reporting agency a!written!summary of your rights and!
remedies !under!the !Washington !Fair!Cred it!Re portin g !Act.!!
ACKNOWLEDGMENT AND AUTHORIZATION
I!acknowledg e !rece ip t !of !the !DISC LOSURE !REGARDING !BA C K G R O U N D !IN V E ST IG A T ION !and A !SUMMAR Y !O F !YO U R !RIG HTS !UND E R !THE !FAIR !CRE D IT
REPORTING ACT!and!certify that I!have !read !and !underst an d !bo th !of !tho se !do cu ments. !I!hereby !auth o riz e !the !ob ta in in g !of !“co n su mer !repo rts ”
and/or “investigative!consumer reports”!by the!Company at any time!after receipt of this authorization and throughout my employment, if
applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution,
school or university!(public!or private), information service b ureau, employer, or insurance company!to furnish any!and all backgroun d information
requested by Validity Screening!Solutions, PO Box!860443, Shawnee, KS!66286-0443, 866.915.0792, www.validityscreening.com, another o utside!
organization!acting on!behalf of the Company, and/or the Company itself. I agree that a facsimile (“fax”), electronic or photographic copy of!this
Authorization!shall be as valid as!the original.
New York applicants or employees only:"!!!By !signing !below, !you !also !acknowledge !receipt !o f !A rtic le !23 -A!of the New York Correction Law.
Minnesota and Oklahoma applicants or employees only: !!Please !check !this !box if !you !would !like !to !receive a !copy !of a !consum er!re p ort if !one is !obtained !by !the
Company.
(Must!include!email!address: )
California applicants or employees only:!!By !signing !below,!you !also !acknowledge !receipt !of !the !NO T IC E !REGARDING !BACKGROUND !INVESTIGATION !PURSUANT !TO
CALIFORNIA!LAW. Please check this box if you!would!like to!receive a copy of an!investigative consumer report or consumer credit report at no!charge if one is
obtained!by the Company whenever you!have a right to!receive such!a copy under California law. www.validityscreening.com/Site/PrivacyPolicy
(Must!include!email!address:
)
Signature: Date:
BACKGROUND INFORMATION
!!First !!!Middle
Date of Birth (mm/dd/yyyy)
[1][2]
State!of Driver’s License
[2]
!!!!!!!Telephone # !(Primary)
Last Name
Other Names/Alias
Social Security #!
[1][2]
Driver’s License #
[2]
Present A ddress
City/State/Zip
[1]
This information will be used for background screening purposes only and will not be used as hiring criteria.
[2]
In !Utah,!this !inform a tio n !may !only
be collected!a) when!extending a conditional offer of employment or b) at the time the background!report will be run.
3 V!1.0 (Issued: November 2012)