disclosure and authorization

Nov 9, 2016 - DISCLOSURE AND AUTHORIZATION. FOR CONSUMER REPORTS. In connection with my application for employment/licensure (including ...

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FOR CONSUMER REPORTS In connection with my application for employment/licensure (including contract or volunteer services) or application to rent a dwelling with ___________________________________, I understand consumer reports will be requested by you (“Company”). These reports may include, as allowed by law, the following types of information, as applicable: names and dates of previous employers, reason for termination of employment, work experience, reasons for termination of tenancy, former landlords, education, accidents, licensure, credit, etc. I further understand that such reports may contain public record information such as, but not limited to: my driving record, workers’ compensation claims, judgments, bankruptcy proceedings, evictions, criminal records, etc., from federal, state, and other agencies that maintain such records. In addition, investigative consumer reports (gathered from personal interviews, as applicable, with former employers or landlords, past or current neighbors and associates of mine, etc.) to gather information regarding my work or tenant performance, character, general reputation and personal characteristics, and mode of living (lifestyle) may be obtained. If I am hired/licensed, I understand that my employer can use this disclosure and authorization to continue to obtain such consumer reports throughout my employment/licensure, contract period or volunteer service. Authorization I hereby authorize procurement of consumer report(s) and investigative consumer report(s) by Company. If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for Company to procure such reports at any time during my employment/licensure, contract or volunteer period. I authorize without reservation, any person, business or agency contacted by the consumer reporting agency to furnish the above-mentioned information. This authorization is conditioned upon the following representations of my rights: I understand that I have the right to make a request to the Consumer Reporting Agency: AmericanChecked Inc., 4870 South Lewis Avenue, Suite 120, Tulsa, OK 74105; telephone: 800-975-9876 (“Agency”) upon proper identification, to obtain copies of any reports furnished to Company by the Agency and to request the nature and substance of all information in its files on me at the time of my request, including the sources of information, and the Agency, on Company’s behalf, will provide a complete and accurate disclosure of the nature and scope of the investigation covered by any investigative consumer report(s). The Agency will also disclose the recipients of any such reports on me which the Agency has previously furnished within the two year period for employment requests, and one year for other purposes preceding my request (California three years). I hereby consent to Company obtaining the above information from the Agency. I understand that I can dispute, at any time, any information that is inaccurate in any type of report with the Agency. I may view the Agency’s privacy policy at their website: http://americanchecked.com/privacy-policy. I understand that if the Company is located in California, Minnesota or Oklahoma, that I have the right to request a copy of any report the Company receives on me at the time the report is provided to the Company. By checking the following box, I request a copy of all such reports be sent to me. Check here:

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AmericanChecked Inc. DISCLOSURE AND AUTHORIZATION 2.2 As a California applicant, I understand that I have the right under Section 1786.22 of the California Civil Code to contact the Agency during reasonable hours (9:00 a.m. to 5:00 p.m. (CST) Monday through Friday) to obtain all information in Agency’s file for my review. I may obtain such information as follows: 1) In person at the Agency’s offices, which address is listed above. I can have someone accompany me to the Agency’s offices. Agency may require this third party to present reasonable identification. I may be required at the time of such visit to sign an authorization for the Agency to disclose to or discuss Agency’s information with this third party; 2) By certified mail, if I have previously provided identification in a written request that my file be sent to me or to a third party identified by me; 3) By telephone, if I have previously provided proper identification in writing to Agency; and 4) Agency has trained personnel to explain any information in my file to me and if the file contains any information that is coded, such will be explained to me. I understand that if I am applying for employment in New York, that I have the right to receive a copy of Article 23-A of the New York Correction Law ____________(initial if this applies). I understand that if the report is provided to an employer in the State of Washington, that I can contact the following office for more information regarding my rights under Washington State Law in regard to these reports: State of Washington Attorney General, Consumer Protection Division, 800 5th Ave, Ste. 2000, Seattle, Washington 98104-3188, (206) 464-7744. In connection with my application for employment/licensure (including contract or volunteer services) or application to rent a dwelling, I direct the following regarding my current employer: (please check one). Yes, my current employer may be contacted ________ / No, my current employer cannot be contacted _________ I understand that I have rights under the Fair Credit Reporting Act, and I acknowledge receipt of the Summary of Rights _____________ (initials). First Name _______________________ Middle Name/MI ________________ Last Name __________________ Signature ________________________________________________________________________________________ Date ________________________

For identification purposes: Address _______________________________________________________________________________ Social Security No. ___________________________ Date of Birth ______________________________________ Driver License No. ____________________________ State of Issue _____________________________________

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