Background Check Disclosure Form

Caregiver Background Check Disclosure Form

Obtaining a Consumer Report (Criminal Background Check) for Employment Purposes

Please Read Carefully Before Signing the Authorization

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 obtained 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 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 credit information, criminal history reports, or driving records.
• 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. In the event an investigative consumer report is requested, you are entitled to additional disclosures regarding the nature and scope of the investigation, as well as a written summary of your rights under the 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 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.

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 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.

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: __________________
Previous Addresses (past 7 years, including street, city, state, zip): __________________________________________________
Date of Birth: ___________
Other Names Used (including maiden name): _____________________________
Social Security Number: ____________
Driver's License # and State: ______________
Email Address: ____________________

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

Printed Name: _____________________________________________    Date: _______________

Applicant Signature: ____________________________________________    Date: _______________

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