please complete all fields below acknowledgment and authorization

I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by (“Employer”) at any time after receipt o...

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DO NOT STAPLE

ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by School District of Ladysmith (“Employer”) 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 bureau, employer, or insurance company to furnish any and all background information requested by Verified First, 1550 South Tech Lane, Suite 200, Meridian, Idaho 83642; Tel. # 1-888-670-9564; www.VerifiedFirst.com and/or Employer. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original. New York applicants only: Upon request, you will be informed whether or not a consumer report was requested by the Employer, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. You have the right to inspect and receive a copy of any investigative consumer report requested by the Employer by contacting the consumer reporting agency identified above directly. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law. New York City applicants only: You acknowledge and authorize the Employer to provide any notices required by federal, state or local law to you at the address(es) and/or email address(es) you provided to the Employer. Washington State applicants 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 Credit Reporting Act. Minnesota and Oklahoma applicants only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Employer.

PLEASE COMPLETE ALL FIELDS BELOW Last Name

First Name

Middle Name

Social Security Number* ###-##-####

Date of Birth* month/date/year

Email Address required

Driver’s License Number

Former Names/Aliases separate aliases with comma

Issuing State*

CURRENT ADDRESS

FORMER EMPLOYER

Street

City

check box if no middle name

State

Apt/Unit

Company

City, State

Zip

Position

Dates of Employment

*This information will be used for background screening purposes only and will not be used as hiring criteria.

Applicant Signature

Date

Revision 07/26/17 www.VerifiedFirst.com

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