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Request for Criminal History Consumer Report

Company Name (Representative)

APPLICANT AUTHORIZATION TO OBTAIN INVESTIGATIVE BACKGROUND REPORT
In connection with my application for employment or promotion or other job change, I hereby instruct and authorize (the “Company”) to obtain an INVESTIGATIVE CONSUMER REPORT on me that will include information as to my character, general reputation, personal characteristics and mode of living. This report may reveal information about my work habits, including oral assessments of my job performance, experiences and abilities, along with reasons for termination of past employment. Such a report may be requested by the Company or on behalf of the Company. Further, I understand and agree that the Company and/or the below-named Consumer Reporting Agency may request information from various federal, state, and other agencies, including public and private sources which maintain records concerning my past activities relating to my driving record, credit history, criminal record, civil matters, previous employment, educational background and professional licensing, if any. This report will be ordered from the below-named Consumer Reporting Agency:

Background Investigations
1685 H Street #1387
Blaine WA 98230
(888) 338-1550
http://www.wedobackgroundchecks.com

APPLICANT’S PERSONAL INFORMATION:

Name:
(Please Print)

(First)

(Middle)

(Last)
Other names used and dates of use:
  1.   Dates 
  2.   Dates 
  3.   Dates 
Social Security Number:   DL#:   State: 
Date of birth*:   Place of birth:   (County and State, or Country)
*Used for positive identification, required.
Height:    Weight:    Hair color:    Eye color:    Gender:  Race: 
Have you been convicted of a crime?   Yes    No    If yes, give details (date, crime, location).





Note: Disclosure of convictions does not automatically disqualify you for employment.
List addresses, cities, states and counties of residence you have lived for the past seven years.
Address City State County From To
Request for Criminal History Consumer Report
DISCLOSURES TO UNDERSIGNED APPLICANT
This is written notice from the Company that an investigative consumer report is being obtained from a consumer reporting agency (CRA) for employment purposes. The undersigned applicant hereby instructs, authorizes and requests any present or former employer, school, police department, financial institution, division of motor vehicles, or other persons or agencies having personal knowledge about the undersigned applicant to furnish the above-named Consumer Reporting Agency with any and all information in their possession regarding the undersigned applicant, in connection with an application for employment. The undersigned applicant hereby instructs, authorizes and requests that a photocopy of this authorization be accepted with the same authority as the original. Under the federal Fair Credit Reporting Act (FCRA) and other applicable state law, you have certain rights with regard to consumer reports obtained for employment purposes including, upon request, disclosure of information on you in the reporting agency’s file at the time of the request, including the identification of persons who have procured a consumer report concerning you, and reasonable opportunity to respond to any information in the report that is disputed by you. The FCRA, 15 U.S.C. 1681, is designed to promote accuracy, fairness, and privacy of information in the files of every “consumer reporting agency” (CRA). You can obtain a copy of any investigative consumer report obtained by Background Investigation, Inc. Request for disclosure of the reporting agency’s file should be made in writing within a 60 day time period to Background Investigations, Inc., PO Box 3366, Lynnwood, WA 98046-3366. If a consumer investigative report is obtained and an adverse decision is made affecting your employment, the Company will provide to you, before making the adverse decision, a copy of the investigative consumer report and a copy of the Federal Trade Commission Publication, A Summary of Your Rights Under the Fair Credit Reporting Act. The undersigned applicant hereby acknowledges that he/she (i) has read or has had read to him/her the above authorization and disclosures, (ii) has understood it, (iii) had the opportunity to consult with and discuss this form with his/her attorney prior to signing this document, and (iv) agrees to be fully bound by it.

Applicant Signature
 
Date
EMPLOYER CERTIFICATION TO CONSUMER REPORTING AGENCY; By submitting this order to the above-referenced Consumer Reporting Agency, the undersigned Company and individual agent signing on behalf of the Company expressly certifies to the above-referenced Consumer Reporting Agency (i) that any reports procured related hereto will be used for employment screening purposes only pursuant to FCRA Section 604(a)(3)(B); (ii) that prior to taking any adverse action, based in whole or in part upon said report(s), the Company will provide the applicant a copy of the report(s) and a copy of the publication, A Summary of Your Rights Under the Fair Credit Reporting Act; and (iii) that said report(s) will not be used in violation of any applicable Federal or State law or regulation including those specifically governing equal employment opportunity.
Employer:

Company Name
By:
Signature of Authorized Agent for Company
Submit
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