Applicant Notification / Release of Information In connection with my application for employment, I understand that investigative inquiries on my background, in accordance with the Fair Credit Reporting Act and all state and federal laws, are to be made on me, including information as to my personal character, abilities, work habits, mode of living, residency, general reputation, performance, experience, and other qualities pertinent to my qualifications for employment, including reasons for termination of past employment. I understand that prospective employer and/or First Check may make inquiries, including but not limited to my consumer credit history, education, professional licensing, and criminal history and driving history. Furthermore, I understand that prospective employer and/or First Check may request information from various federal, state and other agencies that maintain records concerning my past driving history, credit history, criminal history, military history, civil and other experiences. I understand that according to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my perspective employer from a Consumer Reporting Agency. Upon written request, I will be informed whether an investigative consumer report was requested and will be given full information as to the nature and the scope of the investigation, as well as the name of the reporting agency or sources of information. I authorize without reservation, any party (including, but not limited to, employers, law enforcement agencies, state agencies, institutions and private information bureaus or repositories) contacted by prospective employer and/or First Check to furnish any or all of the above mentioned information. In addition, I hereby release First Check and prospective employer from any and all liability for damages arising from the investigation and disclosure of the requested information. I further release and discharge all liability from all companies, agencies, officials, officers, employees and other persons, who, in good faith provide to prospective employer and/or First Check the above mentioned information as requested, in order to successfully complete a background investigation for my application of employment. I will allow a photocopy of this authorization to be as valid as the original. Print Full Name: Social Security *Date of Birth / / Current Address City/State/Zip Driver s License # State Prospective Employer Applicants Signature ** Notary Signature Printed State County Commission Expires * Date of birth is being requested only for the purpose of identification in obtaining accurate retrieval of records, and will not be used for discriminatory purposes. ** Only when requested
1500 CORPORATE CIRCLE STE 16 817-410-8383 SAMPLE CONSUMER DISCLOSURE CONFIDENTIAL TO BE OPENED BY ADDRESEE ONLY JONATHAN Q CONSUMER 123 MAIN ST DALLAS, TX 75201 August 12, 2004 Dear JONATHAN CONSUMER, We are writing to inform you that in evaluating your application for employment we have received the enclosed consumer report. This notification is provided because an adverse decision may be based, in whole or part, on this report. We are hereby informing you of certain information pursuant to the Fair Credit Reporting Act. The report was prepared pursuant to an authorization signed by you at the time of application. A summary of your rights as a consumer is enclosed. If you have any questions regarding this report or believe that it may contain incorrect information, you may contact this company and they will respond to your inquiry. Their mailing address and phone number are listed below: 1500 CORPORATE CIRCLE SUITE 16 SOUTHLAKE, TX 76092 Voice: 817-410-8383 Fax: 817-329-9569 only provided us the consumer report and plays no part in the decision to take any action on your employment application. is unable to provide you with specific reasons for any employment related decisions to be made. Sincerely, Enc. Consumer Report Consumer Rights Notification * 1500 CORPORATE CIRCLE STE 16 Phone 817-410-8383 * Fax 817-329-9569 Summary of Your Rights Under the Fair Credit Reporting Act The Federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the files of every "consumer reporting agency". Most CRAs are credit bureaus that gather and sell information about you - such as if you pay your bills on time or have filed bankruptcy - the creditors, employers, landlords, and other businesses. You can find the complete text of the FCRA, 15 U.S.C. 1681-1681u, at the Federal Trade Commission's web site (http://www.ftc.gov). The FCRA gives you specific rights, as outlined below. You may have additional rights under state law. You may contact a state or local consumer protection agency or a state attorney general to learn those rights. You must be told if information in your file has been used against you. Anyone who uses information from a CRA to take action against you - such as denying an application for credit, insurance, or employment - must tell you, and give you the name, address, and phone number of the CRA that provided the consumer report. You can find out what is in your file. At your request, a CRA must give you the information in your file, and a list of everyone who has requested it recently. There is no charge for the report is a person has taken action against you because of information supplied by the CRA, if you request the report within 60 days of receiving notice of the action. You also are entitled to one free report every twelve months upon request if you certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on welfare, or (3) your report is inaccurate due to fraud. Otherwise, a CRA may charge you up to eight dollars. You can dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurate information, the CRA must investigate the items (usually within 30 days) by presenting to its information source all relevant evidence you submit, unless your dispute is frivolous. The source must review your evidence and report its findings to the CRA.
(The source also must advise national CRAs - to which it has provided the data - of any error.) The CRA must give you a written report of the investigation, and a copy of your report if the investigation results in any change. If the CRA's investigation does not resolve the dispute, you may add a brief statement to your file. The CRA must normally include a summary of your statement in future reports. If an item is deleted or a dispute statement is filed, you may ask that anyone who has recently received your report be notified of the change. Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate or unverified information from its files, usually within 30 days after you dispute it. However, the CRA is not required to remove accurate data from your file unless it is outdated (as described below) or cannot be verified. If your dispute results in any change to your report, the CRA cannot reinsert into your file a disputed item unless the information source verifies its accuracy and completeness. In addition, the CRA must give you a written notice telling you it has reinserted the item. The notice must include the name, address and phone number of the information source. You can dispute inaccurate items with the source of the information. If you tell anyone - such as a creditor who reports to a CRA - that you dispute an item, they may not then report the information to a CRA without including a notice of your dispute. In addition, once you've notified the source of the error in writing, it may not continue to report the information if it is, in fact, an error. Outdated information may not be reported. In most cases, a CRA may not report negative information that is more than seven years old: ten years for bankruptcies. Access to your file is limited. A CRA may provide information about you only to people with a need recognized by the FCRA - usually to consider an application with a creditor, insurer, employer, landlord, or other business. Your consent is required for reports that are provided to employers, or reports that contain medical information. A CRA may not give out information about you to your employer, or prospective employer, without your written consent. A CRA may not report medical information about you to creditors, insurers, or employers without your permission. You may choose to exclude your name from CRA lists for unsolicited credit and insurance offers. Creditors and insurers may use file information as the basis for sending you unsolicited offers of credit or insurance. Such offers must include a toll-free phone number for you to call if you want your name and address removed from future lists. If you call, you must be kept off the lists for two years. If you request, complete, and return the CRA form provided for this purpose, you must be taken off the lists indefinitely. You may seek damages from violators. If a CRA, a user or (in some cases) a provider of CRA data, violates the FCRA, you may sue them in state or federal court. The FCRA gives several different federal agencies authority to enforce the FCRA: FOR QUESTIONS OR CONCERNS REGARDING: PLEASE CONTACT: CRAs, creditors and others not listed below Federal Trade Commission Consumer Response Center - FCRA Washington, DC 20580 * 202-326-3761 National banks, federal branches/agencies of Foreign banks (word "National" or initials "N.A." appear in or after bank's name) Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC 20219 * 800-613-6743 Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks) Federal Reserve Board Division of Consumer & Community Affairs Washington, DC 20551 * 202-452-3693 Savings associations and federally chartered savings banks (word "Federal" or initials "F. S. B." appear in federal institution's name) Office of Thrift Supervision Consumer Programs Washington, DC 20552 * 800-842-6929
Federal credit unions (words "Federal Credit Union" appear in institution's name) National Credit Union Administration 1775 Duke Street Alexandria, VA 22314 * 703-518-6360 State-chartered Banks that are not members of the Federal Reserve System Federal Deposit Insurance Corporation Division of Compliance & Consumer Affairs Washington, DC 20429 * 800-934-FDIC Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission Department of Transportation Office of Financial Management Washington, DC 20590 * 202-366-1306 Activities subject to the Packers and Stockyards Act, 1921 Department of Agriculture Office of Deputy Administrator - GIPSA Washington, DC 20250 * 202-720-7051
1500 CORPORATE CIRCLE STE 16 817-410-8383 SAMPLE ADVERSE ACTION NOTICE CONFIDENTIAL TO BE OPENED BY ADDRESEE ONLY JONATHAN Q CONSUMER 123 MAIN ST DALLAS, TX 75201 August 12, 2004 Dear JONATHAN CONSUMER, This letter is to inform you that an offer of employment will not be made at this time. This decision was based in whole or in part, on the information provided us in a Consumer Report or Investigative Consumer Report. The report was repaired pursuant to an authorization signed by you at the time of application. Further at that time you received a copy of your consumer report and a summary of your rights under the Fair Credit Reporting Act. The consumer report was used only for employment purposes and prepared for us by a consumer-reporting agency. Their mailing address and phone number are listed below: 1500 CORPORATE CIRCLE SUITE 16 SOUTHLAKE, TX 76092 Voice: 817-410-8383 Fax: 817-329-9569 plays no part in the decision to take any action on your employment application. is unable to provide you with specific reason(s) for not extending an offer of employment. You may, upon providing proper identification, request another free copy of the report and may dispute with the consumer reporting agency the completeness or accuracy of any information in the report within 60 days of receipt of this notice with. Sincerely, * 1500 CORPORATE CIRCLE STE 16 Phone 817-410-8383 * Fax 817-887-1467