This form is provided as a sample, may not be suitable for every situation or every company and should not be considered legal advice or legal opinion. There may be state or municipality specific information that would affect your use of this form. You should review applicable law in your jurisdiction and consult experienced counsel for legal advice. If you use this form (either “as is” or by modifying the form), you are responsible for all content.
YOU SHOULD REMOVE THIS TEXT BEFORE USING THE FORM IN YOUR WORKPLACE.

BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION FORM

In the interest of maintaining the safety and security of our customers, employees and property, __________________________ (the “Company”) will order a “consumer report” (a background report) or “investigative consumer report" on you in connection with your employment application, and if you are hired, or if you already work for the Company, may order additional background reports on you for employment purposes.

The background check company, ADP Screening and Selection Services, will prepare the background report for the Company. ADP Screening and Selection Services is located at 301 Remington Street, Fort Collins, CO, 80524, and can be reached by phone at 800-367-5933 or at their Internet Web site address www.adpselect.com.

The background report may contain information concerning your character, general reputation, personal characteristics, mode of living, and credit standing. The types of information that may be ordered include but are not limited to: Social Security number verification; criminal, public, educational and, as appropriate, driving records checks; verification of prior employment; reference, licensing and certification checks; credit reports; drug testing results; and, if applicable, worker’s compensation injuries. Workers’ compensation information will only be requested in compliance with federal Americans with Disabilities Act and/or any other applicable federal, state or local laws and only after a conditional job offer is made. Credit history will only be requested when permitted by law and where such information is substantially related to the duties and responsibilities of the position for which you are applying. The information may be obtained from private and public record sources, including personal interviews with your associates, friends, and neighbors. (An “investigative consumer report” is a background report that includes information from such personal interviews, except in California where that term means any background report that is not a credit report.) The nature and scope of the most common form of investigative consumer report is an investigation into your education and/or employment history conducted by ADP Screening and Selection Services or another outside organization.

You may request more information about the nature and scope of an investigative consumer report, if any, by telephoning the Company at ____-____-_____. A summary of your rights under the Fair Credit Reporting Act is also being provided to you with this form.

The Fair Credit Reporting Act gives you specific rights in dealing with consumer reporting agencies. You will find these rights summarized on A Summary of Your Rights Under the Fair Credit Reporting Act and A Summary of Your Rights Under the Provisions of California Civil Code Section 1786.22 as provided here.

STATE LAW NOTICES
If you live or work for the Company in the states listed below, please note the following:
CALIFORNIA: You may view the file that ADP Screening and Selection Services has for you, and order a copy of the file, upon submitting proper identification and paying copying costs, by coming to their offices, during normal business hours and on reasonable notice, or by certified mail or mail. You may also ask for a file-summary by telephone. ADP Screening and Selection Services can answer questions about information in your file, including any coded information. If you come in person, another person can come with you, so long as that person can show proper identification.

MAINE: If you ask us, you have the right to know whether the Company ordered an investigative consumer report on you. You may request the name, address, and telephone number of the nearest office for ADP Screening and Selection Services. You will get this information within 5 business days of our receipt of your request. You have the right to ask ADP Screening and Selection Services for a free copy of the report.

MARYLAND: If the Company obtains credit history information on you, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.

MASSACHUSETTS/NEW JERSEY: If you submit a request to us in writing, you have the right to know whether the Company ordered an investigative consumer report from ADP Screening and Selection Services. You may inspect and order a free copy of the report by contacting ADP Screening and Selection Services.

MINNESOTA: If you submit a request to us in writing, you have the right to get from the Company a complete and accurate disclosure of the nature and scope of the consumer report or investigative consumer report ordered, if any.

NEW YORK: If you submit a request to us in writing, you have the right to know whether the Company ordered a consumer report or an investigative consumer report from ADP Screening and Selection Services, and you will be provided with the name and address of ADP Screening and Selection Services. You may inspect and order a free copy of the reports by contacting ADP Screening and Selection Services. By signing below, you certify you have received a copy of Article 23A of the New York Correction Law is being provided with this form.

OREGON: If the Company obtains credit history information on you, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.

WASHINGTON STATE: If you submit a request to us in writing, you have the right to get from the Company a complete and accurate disclosure of the nature and scope of the investigative consumer report we ordered, if any. You also have the right to ask ADP Screening and Selection Services for a written summary of your rights under the Washington Fair Credit Reporting Act. If the Company obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.

AUTHORIZATION FOR BACKGROUND CHECKS

After carefully reading this Background Check Disclosure and Authorization form, I authorize the Company to order my background report, including investigative consumer reports. I understand that the Company may rely on this authorization to order additional background reports, including investigative consumer reports, during my employment without asking me for my authorization again as allowed by law.

I also authorize the following agencies and entities to disclose to ADP Screening and Selection Services and its agents all information about or concerning me, including but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; if applicable, worker’s compensation injuries; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. Workers’ compensation information will only be requested in compliance with federal Americans with Disabilities Act and/or any other applicable federal, state or local laws and only after a conditional job offer is made. The information that can be disclosed to ADP Screening and Selection Services and its agents includes, but is not limited to, information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses and substance abuse testing.

I agree the Company may rely on this authorization to order background reports, including investigative consumer reports, from companies other than ADP Screening and Selection Services without asking me for my authorization again as allowed by law. I also agree that a copy of this form is valid like the signed original. I certify that all of the personal information I provided is true and correct.

Last Name __________________________________ First ________________________ Middle ____________________

Maiden/Other Names _______________________________________________ Years Used _______________________

If you live or work for the Company in California, Minnesota or Oklahoma: Check this box if you would like a free copy of your background check report: (

______________________________________________________________ _____/_______/________
Signature Date: (Month/Day/Year)

If required, notarize here. When using an embossed seal, Subscribed and sworn before me:

please shade with a pencil before faxing. _____________________________________ Notary Public Signature _____________________________________ Date _____________________________________ My Commission Expires

BACKGROUND CHECK INFORMATION:

The information requested below is collected solely for the purpose of aiding the Company in running a background check in connection with your application for employment. The employer is requesting that you provide this information to assist in conducting a thorough background check.

For residents of, or for jobs located in Utah, please do NOT provide your date of birth, social security number or driver’s license number until instructed to do so by the Company.

First Name _______________________Middle Name __________________Last Name_________________________

Date of Birth ____/____/____ (Month/Day/Year)

Social Security Number ____________________________________________________

Driver’s License Number ______________________________ State Issuing License_________________________

Enter Any Other Names Used (including maiden names):
First Name _________________________Middle Name __________________Last Name_________________________
First Name _________________________Middle Name __________________Last Name_________________________
First Name _________________________Middle Name __________________Last Name_________________________

Addresses Within The Past Seven Years (use a separate sheet as needed)

Present Street Address ___________________________________________________________

City/State/ZIP ___________________________________________________________________________

Prior Street Address _________________________________________________________________

From _____/_______/______ (Month/Day/Year) To _____/_______/______ (Month/Day/Year)

City/State/ZIP __________________________________________________________________________

Para informacion en espanol, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

• You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information. • You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if: ← a person has taken adverse action against you because of information in your credit report; ← you are the victim of identity theft and place a fraud alert in your file; ← your file contains inaccurate information as a result of fraud; ← you are on public assistance; ← you are unemployed but expect to apply for employment within 60 days.
In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information. • You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender. • You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures. • Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate. • Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old. • Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access. • You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore. • You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-800-XXX-XXXX. • You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court. • Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local protection agency or your state Attorney General. For information about your federal rights, contact:

|TYPE OF BUSINESS: |CONTACT: |
|1.a. Banks, savings associations, and credit unions with total assets of over |Consumer Financial Protection Bureau |
|$10 billion and their affiliates. |1700 G Street, N.W. |
| |Washington, DC 20552 |
|b. Such affiliates that are not banks, savings associations, or credit unions |Federal Trade Commission: Consumer Response Center – FCRA |
|also should list, in addition to the CFPB: |Washington, DC 20580 |
| |(877) 382-4357 |
|2. To the extent not included in item 1 above: |Office of the Comptroller of the Currency |
| |Customer Assistance Group |
|National banks, federal savings associations, and federal branches and federal |1301 McKinney Street, Suite 3450 |
|agencies of foreign banks |Houston, TX 77010-9050 |
|State member banks, branches and agencies of foreign banks (other than federal |Federal Reserve Consumer Help Center |
|branches, federal agencies, and Insured State Branches of Foreign Banks), |P.O. Box 1200 |
|commercial lending companies owned or controlled by foreign banks, and |Minneapolis, MN 55480 |
|organizations operating under section 25 or 25A of the Federal Reserve Act |FDIC Consumer Response Center |
|Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured |1100 Walnut Street, Box # 11 |
|state savings associations |Kansas City, MO 64106 |
|Federal Credit Unions |National Credit Union Administration |
| |Office of Consumer Protection (OCP) |
| |Division of Consumer Compliance and Outreach (DCCO) |
| |1775 Duke Street |
| |Alexandria, VA 22314 |
|3. Air carriers |Asst. General Counsel for Aviation Enforcement & Proceedings |
| |Aviation Consumer Protection Division |
| |Department of Transportation |
| |1200 New Jersey Avenue, S.E. |
| |Washington, DC 20590 |
|4. Creditors Subject to the Surface Transportation Board |Office of Proceedings, Surface Transportation Board |
| |Department of Transportation |
| |395 E Street, S.W. |
| |Washington, DC 20423 |
|5. Creditors Subject to the Packers and Stockyards Act, 1921 |Nearest Packers and Stockyards Administration area supervisor |
|6. Small Business Investment Companies |Associate Deputy Administrator for Capital Access |
| |United States Small Business Administration |
| |409 Third Street, SW, 8th Floor |
| |Washington, DC 20416 |
|7. Brokers and Dealers |Securities and Exchange Commission |
| |100 F Street, N.E. |
| |Washington, DC 20549 |
|8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate |Farm Credit Administration |
|Credit Banks, and Production Credit Associations |1501 Farm Credit Drive |
| |McLean, VA 22102-5090 |
|9. Retailers, Finance Companies, and All Other Creditors Not Listed Above |FTC Regional Office for region in which the creditor operates or Federal Trade |
| |Commission: Consumer Response Center – FCRA |
| |Washington, DC 20580 |
| |(877) 382-4357 |

A Summary of Your Rights
Under the Provisions of California Civil Code Section 1786.22

The Investigative Consumer Reporting Agencies Act (ICRA) is designed to promote accuracy, fairness, and privacy of information in the files of every "consumer reporting agency" (CRA). You can find the complete text of the ICRA, at the California Privacy Protection web site (http://www.privacy.ca.gov/icraa.htm). The ICRA gives you specific rights, as outlined below. You may have additional rights under federal law. You may contact a state or local consumer protection agency or a state attorney general to learn those rights.

(a) An investigative consumer reporting agency shall supply files and information required under Section 1786.10 during normal business hours and on reasonable notice.

(b) Files maintained on a consumer shall be made available for the consumer's visual inspection, as follows:
(1) In person, if he appears in person and furnishes proper identification. A copy of his file shall also be available to the consumer for a fee not to exceed the actual costs of duplication services provided.
(2) By certified mail, if he makes a written request, with proper identification, for copies to be sent to a specified addressee. Investigative consumer reporting agencies complying with requests for certified mailings under this section shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the investigative consumer reporting agencies.
(3) A summary of all information contained in files on a consumer and required to be provided by Section 1786.10 shall be provided by telephone, if the consumer has made a written request, with proper identification for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to the consumer.

(c) The term "proper identification" as used in subdivision (b) shall mean that information generally deemed sufficient to identify a person. Such information includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. Only if the consumer is unable to reasonably identify himself with the information described above, may an investigative consumer reporting agency require additional information concerning the consumer's employment and personal or family history in order to verify his identity.

(d) The investigative consumer reporting agency shall provide trained personnel to explain to the consumer any information furnished him pursuant to Section 1786.10.

(e) The investigative consumer reporting agency shall provide a written explanation of any coded information contained in files maintained on a consumer. This written explanation shall be distributed whenever a file is provided to a consumer for visual inspection as required under Section 1786.22.

(f) The consumer shall be permitted to be accompanied by one other person of his choosing, who shall furnish reasonable identification. An investigative consumer reporting agency may require the consumer to furnish a written statement granting permission to the consumer reporting agency to discuss the consumer's file in such person's presence.

NEW YORK CORRECTION LAW
ARTICLE 23-A
LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY
CONVICTED OF ONE OR MORE CRIMINAL OFFENSES Section 750. Definitions. 751. Applicability. 752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited. 753. Factors to be considered concerning a previous criminal conviction; presumption. 754. Written statement upon denial of license or employment. 755. Enforcement. §750. Definitions. For the purposes of this article, the following terms shall have the following meanings:
(1) "Public agency" means the state or any local subdivision thereof, or any state or local department, agency, board or commission.
(2) "Private employer" means any person, company, corporation, labor organization or association which employs ten or more persons.
(3) "Direct relationship" means that the nature of criminal conduct for which the person was convicted has a direct bearing on his fitness or ability to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in question.
(4) "License" means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions or instrumentalities as a condition for the lawful practice of any occupation, employment, trade, vocation, business, or profession. Provided, however, that "license" shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire any explosive, pistol, handgun, rifle, shotgun, or other firearm.
(5) "Employment" means any occupation, vocation or employment, or any form of vocational or educational training. Provided, however, that "employment" shall not, for the purposes of this article, include membership in any law enforcement agency.
§751. Applicability. The provisions of this article shall apply to any application by any person for a license or employment at any public or private employer, who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any license or employment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdiction preceded such employment or granting of a license, except where a mandatory forfeiture, disability or bar to employment is imposed by law, and has not been removed by an executive pardon, certificate of relief from disabilities or certificate of good conduct. Nothing in this article shall be construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with an application for employment made by a prospective employee or previously made by a current employee.
§752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited. No application for any license or employment, and no employment or license held by an individual, to which the provisions of this article are applicable, shall be denied or acted upon adversely by reason of the individual's having been previously convicted of one or more criminal offenses, or by reason of a finding of lack of "good moral character" when such finding is based upon the fact that the individual has previously been convicted of one or more criminal offenses, unless:
(1) There is a direct relationship between one or more of the previous criminal offenses and the specific license or employment sought or held by the individual; or
(2) the issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk to property or to the safety or welfare of specific individuals or the general public. §753. Factors to be considered concerning a previous criminal conviction; presumption.
1. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall consider the following factors: (a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons previously convicted of one or more criminal offenses. (b) The specific duties and responsibilities necessarily related to the license or employment sought or held by the person. (c) The bearing, if any, the criminal offense or offenses for which the person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities. (d) The time which has elapsed since the occurrence of the criminal offense or offenses. (e) The age of the person at the time of occurrence of the criminal offense or offenses. (f) The seriousness of the offense or offenses. (g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct. (h) The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of specific individuals or the general public.
2. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein.
§754. Written statement upon denial of license or employment. At the request of any person previously convicted of one or more criminal offenses who has been denied a license or employment, a public agency or private employer shall provide, within thirty days of a request, a written statement setting forth the reasons for such denial. §755. Enforcement.
1. In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to article seventy-eight of the civil practice law and rules.
2. In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights pursuant to the powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city commission on human rights.