I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE
FAIR CREDIT REPORTING ACT (A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT is available by clicking here.
You may save or print a copy for your records) 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 the Company 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 Professional Screening Services, Inc., 996 Westwood Square, Suite 2, Oviedo, Florida, 32765, (800) 578-5415 or (407) 423-8766, or another outside
organization acting on behalf of The Company and/or The Company itself. I agree that a facsimile (“fax”), electronic or photographic copy of this
Authorization shall be as valid as the original.
New York applicants or employees only: By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law.
(Article 23-A of the New York Correction Law is available by clicking here. You may save or print a copy for your records).
Minnesota and Oklahoma applicants or employees only: Please check the box directly below if you would like to receive a copy of a consumer report if one is
obtained by the Company.
California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND
INVESTIGATION PURSUANT TO CALIFORNIA LAW (found below.)
Please check the box directly below if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is
obtained by the Company whenever you have a right to receive such a copy under California law.
NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW
Hello!. (the “Company”) intends to obtain information about you for employment purposes from a consumer reporting agency. Thus,
you can expect to be the subject of “investigative consumer reports” and “consumer credit reports” obtained for employment purposes. Such reports may
include information about your character, general reputation, personal characteristics and mode of living. With respect to any investigative consumer report
from an investigative consumer reporting agency (“ICRA”), the Company may investigate the information contained in your employment application and
other background information about you, including but not limited to obtaining a criminal record report, verifying references, work history, your social
security number, your educational achievements, licensure, and certifications, your driving record, and other information about you, and interviewing people
who are knowledgeable about you. The results of this report may be used as a factor in making employment decisions. The source of any investigative
consumer report (as that term is defined under California law) or any credit report information will be Professional Screening Services, Inc., located at 996
Westwood Square, Suite 2, Oviedo, Florida, 32765, (800) 578-5415 or (407) 423-8766. The Company agrees to provide you with a copy of an investigative
consumer report when required to do so under California law.
Under California Civil Code section 1786.22, you are entitled to find out from an ICRA what is in the ICRA’s file on you with proper identification, as follows:
• In person, by visual inspection of your file during normal business hours and on reasonable notice. You also may request a copy of the information in person.
The ICRA may not charge you more than the actual copying costs for providing you with a copy of your file.
• A summary of all information contained in the ICRA’s file on you that is required to be provided by the California Civil Code will be provided to you via
telephone, if you have 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 you.
• By requesting a copy be sent to a specified addressee by certified mail. ICRAs complying with requests for certified mailings shall not be liable for
disclosures to third parties caused by mishandling of mail after such mailings leave the ICRAs.
“Proper Identification” includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. Only
if you cannot identify yourself with such information may the ICRA require additional information concerning your employment and personal or family history
in order to verify your identity.
The ICRA will provide trained personnel to explain any information furnished to you and will provide a written explanation of any coded information
contained in files maintained on you. This written explanation will be provided whenever a file is provided to you for visual inspection.
You may be accompanied by one other person of your choosing, who must furnish reasonable identification. An ICRA may require you to furnish a written
statement granting permission to the ICRA to discuss your file in such person’s presence.
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