Acknowledgment & Authorization for Background Check

Background Information

Name *

First

Middle

Last

Other Names/Alias

Social Security Number *

This information will be used for background screening purposes only and will not be used as hiring criteria.

Date of Birth *

This information will be used for background screening purposes only and will not be used as hiring criteria.

Driver’s License #

This information will be used for background screening purposes only and will not be used as hiring criteria.

Driver’s License State

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Former Employer

Position

Dates of Employment

Referred to FINFROCK by:

ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK

I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT 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 Employer 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 Edge Information Management, Incorporated, 1682 W. Hibiscus Blvd., Melbourne, Florida 32901, 1-800-725-3343, www.edgeinformation.com, and/or Employer itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

New York applicants only:
Upon request, you will be informed whether or not a consumer report was requested by the Company, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. You have the right to inspect and receive a copy of any investigative consumer report requested by the Company by contacting the consumer reporting agency identified above directly. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law.

Washington State applicants only:
You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

Minnesota and Oklahoma applicants only:

Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company.

California applicants only:
Under California Civil Code section 1786.22, you are entitled to find out what is in the CRA’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 CRA 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 CRA 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. CRAs 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 CRAs.

“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 CRA require additional information concerning your employment and personal or family history in order to verify your identity. The CRA 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. A CRA may require you to furnish a written statement granting permission to the CRA to discuss your file in such person’s presence.

California applicants only:

Please check this box 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 Credit Checks Per California Law:

An employee covered by the executive exemption set forth in subparagraph (1) of paragraph (A) of Section 1 of Wage Order 4 of the Industrial Welfare Commission;
A position in the state Department of Justice;
A sworn peace officer or other law enforcement;
A position for which the information contained in the report is required by law to be disclosed or obtained;
A position that involves regular access to specified personal information for any purpose other than the routine solicitation and processing of credit card applications in a retail establishment, such as bank or credit card account information, social security number, or date of birth;
A position which the person can enter into financial transactions on behalf of the company;
A position that involves access to confidential or proprietary information;
A position that involves regular access to $10,000 or more of cash; or
The Company will not obtain a consumer credit report on you.

NOTICE REGARDING CREDIT CHECKS PER VERMONT LAW

Pursuant to Vermont Act No. 154 (S. 95), the Company informs you that it may obtain a credit report about you, for the following reason(s):

The information is required by state or federal law or regulation;
You seek to be/are employed in a position that involves access to “confidential financial information” (defined as “sensitive financial information of commercial value that a customer or client of the employer gives explicit authorization for the employer to obtain, process, and store and that the employer entrusts only to managers or employees as a necessary function of their job duties”);
The Company is a financial institution as defined in 8 V.S.A. §11101(32) or a credit union as defined in 8 V.S.A. §30101(5);
You seek to be/are employed in a position as a law enforcement officer, emergency medical personnel or firefighter as these terms are respectively defines in 20 V.S.A. §2358, 24 V.S.A. §2651(6) and 20 V.S.A. §3151(3)
You seek to be/are employed in a position that requires a financial fiduciary responsibility to the Company or a Company’s clients, including the authority to issue payments, collect debts, transfer money or enter into contracts;
You seek to be/are employed in a position that involves access to the Company’s payroll information;
The Company can demonstrate that credit information is a valid and reliable predictor of employee performance in the your specific position of employment;
The Company will not obtain a consumer credit report on you.

Date *