Background Check Disclosure Form                  BUY BC NOW

(This is a sample only, as laws can change at anytime but is similar to what many companies use to comply with the FCRA).

Caregiver Background Check Disclosure Form to Obtain Consumer Report (Criminal Background Check) for Employment Purposes

Please Read Carefully Before Signing the Authorization         

Background Check Disclosure Form

In considering you for employment and, if you are employed, in considering you for subsequent promotion, assignment, reassignment, retention, or discipline,

[ INSERT NAME OF COMPANY ] (“the Company”) may request and rely upon one or more consumer reports or investigative consumer reports about you that we obtain from a consumer reporting agency.

For explanation purposes:
a “consumer report” is a written, oral or other communication of any information by a consumer reporting agency bearing on your credit-worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in making an employment-related decision about you. Such information may include, for example, credit information, criminal history reports, or driving records; and an “investigative consumer report” is a consumer report in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your prior employers, neighbors, friends, or associates, or with others who may have knowledge concerning any such items of information. In the event an investigative consumer report is requested about you, you are entitled to additional disclosures regarding the nature and scope of the investigation requested, as well as a written summary of your rights under the Fair Credit Reporting Act (“FCRA”).

Under the FCRA, before the Company can obtain a consumer report or investigative consumer report about you for employment purposes, we must have your written authorization. Before we take adverse action on the basis, in whole or in part, of information in that report, you will be provided a copy of that report, the name, address, and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA.

Caregiver Background Check Authorization Form

I have read and understand the foregoing Disclosure, and authorize the Company to obtain and rely upon consumer reports or investigative consumer reports in considering me for employment and, if I am employed, in considering me for subsequent promotion, assignment, reassignment, retention, or discipline. By my signature below, I authorize the Company to obtain any such reports and to share the information received with any person involved in the employment decision about me.

I do _______do not_________ authorize you to contact my current employer for Employment and Reference Verifications (This will authorize immediate inquiries to the Human Resources Department and to any listed supervisors or references in the Employment/Reference Section of your application.)

I also agree that this Disclosure and Authorization in original, faxed, photocopied, or electronic (including electronically signed) form will be valid for any consumer reports or investigative consumer reports that may be requested about me by or on behalf of the Company.

_______________________________ ________________
Applicant Signature Date

Personal Data

Last Name: ______________________
First Name: ______________________
Middle Name: ____________________
Current Address: ___________________
Dates Lived Here: __________________
Addresses for the Past Seven Years: (include street, city, state, zip code) Dates of Residence: __________________________________________________
Date of Birth: ___________
Other Names Used (including maiden name): _____________________________
Years Used: __________________
Social Security Number: ____________
Driver's License # State: ______________
Email address (may be used for official correspondence): ____________________

I have the right to make a request to Consumer Report Provider, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including sources of information, and the recipients of any reports on me which Consumer Report Provider has previously furnished within the two year period preceding my request.

I certify that all of elements of the personal data I have provided are true, accurate and complete. I understand and agree that any omission, false statement, misleading statement, or answer made by me on my application or any supplements to it and in any interviews will be sufficient grounds for rejection of employment and my discharge after employment.

_____________________________________________ _______________
Printed Name Date

____________________________________________ _______________
Applicant Signature Date

ADDITIONAL STATE LAW REQUIREMENTS DISCLAIMER: THE DISCLOSURE AND AUTHORIZATION FORM, AND THE DISCUSSION OF STATE REQUIREMENTS BELOW, ARE NOT MEANT TO PROVIDE LEGAL ADVICE OF ANY KIND. LEGAL ADVICE SHOULD BE SOUGHT FROM YOUR ATTORNEY IN CONNECTION WITH THE USE OF THESE FORMS OR THE DETERMINATION OF STATE LAW REQUIREMENTS THAT MAY BE APPLICABLE TO YOU. PROVIDING THIS FORM MAKES NO CLAIMS, PROMISES OR GUARANTEES ABOUT THE ACCURACY, COMPLETENESS, OR ADEQUACY OF THE INFORMATION CONTAINED HEREIN.

IN ADDITION TO THE FOREGOING DISCLOSURE AND AUTHORIZATION FORM NEEDED TO COMPLY WITH THE FEDERAL FAIR CREDIT REPORTING ACT, VARIOUS STATES IMPOSE ADDITIONAL DISCLOSURE OR OTHER OBLIGATIONS ON EMPLOYERS WHEN THEY OBTAIN CONSUMER REPORTS OR INVESTIGATIVE CONSUMER REPORTS ON EMPLOYEES OR APPLICANTS.

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