Background Check Disclosure and Authorization Form
V0611
BACKGROUND CHECK DISCLOSURE AND AUT HORIZATION FORM
In the interest of maintaining the safety and security of our customers, employees and property, __________________________ (the
“Company”) will order a “consumer report” (a background report) on you in connection with your employment application, and if you are
hired, or if you alread y work for the Company, may order additional background reports on you for employment purposes.
The background check company, ADP Screening and Selection Services, will prepare the background report for the Company. ADP
Screening and Selection Servic es is located at 301 Remington Street, Fort Collins, CO, 80524, and can be reached at 800-367-593 3.
The background report may contain information concerning your character, general reputation, personal characteristics, mode of living,
and credit standing. The types of information that may be ordered include but are not limited to: Social Security number verification;
criminal, public, educational and, as appropriate, driving records checks; verification of prior employment; reference, licensing and
certification checks; credit reports; and drug testing results. The information may be obtained from private and public record sources,
including personal interviews with your associates, friends, and neighbors. (An “investigative consumer report” is a background report
that includes information from such personal interviews, except in California where that term means any background report.) The nature
and scope of the most common form of investigative consumer report is an investigation into your education and/or employment history
conducted by ADP Screening and Selection Services or another outside orga nization.
You may requ est more information a bout the nature and scope of an invest igative consumer report, if an y, by telephon ing the Company at
____-____-_____. A summary of your rights under the Fair Credit Reporting Act is also being provided to you with this form.
ST ATE SPECIFIC NOTICES
If you live or work for the Company in the states listed bel ow, please note the follo wing:
CALIFORNIA: You may view the file that ADP Screening and Selection Services has for you, and order a copy of the file, upon
submitting proper identification and paying copying costs, by coming to their offices, during normal business hours and on reasonable
notice, or by mail. You may also ask for a file-summary by telephone. ADP Screening and Selection Services can answer questions
about information i n your file, inclu ding any coded inform ation. If you come in p erson, another person can com e with you, so long as that
person can show proper identification.
MAINE: If you ask us, you have the right to know whether the Company ordered an investigative consumer report on you. You may
request the name, address, and telephone number of the nearest office for ADP Screening and Selection Services. You will get this
information within 5 business days of our receipt of your request. You have the right to ask ADP Screening and Selection Services for a
free copy of the report.
MARYLAND: If the Company obtains credit history information on you, it will be used to evaluate whether you would present an
unacceptable ri sk of theft or other dishonest beh avior in the job for which you are being consi dered.
MASSACHUSETTS/NEW JERSEY: If you s ubmit a req ues t to us in writing, you have the right to know whether the Compan y or dered an
investigative consumer report from ADP Screening and Selection Services. You may inspect and order a free copy of the report by
contacting ADP Screening and Selection Services.
MINNESOTA: If you submit a request to us in writing, you have the right to get from the Company a complete a nd accurate disclosur e of
the nature and scope of the consumer report or investigative consumer report ordered, if any.
NEW YORK: If you submit a request to us in writing, you have the right to know whether the Company ordered a consumer report or an
investigative consumer report from ADP Screening and Selection Services, and you will be provided with the name and address of ADP
Screening and Selection Services. You may inspect and order a free copy of the reports by contacting ADP Screening and Selection
Services. A copy of Article 23A of the Ne w York Correction Law is being provided with this form.
OREGON: If the Company obtains credit history information on you, it will be used to evaluate whether you would present an
unacceptable ri sk of theft or other dishonest beh avior in the job for which you are bei ng considere d.
WASHINGTON STATE: If you submit a request to us in writing, you have the right to get from the Company a complete and accurate
disclosure of the nat ure and s cope of the inv estigativ e cons umer re port we order ed, if an y. You also hav e the r ight to ask ADP Screening
and Selection Services for a written summary of your rights under the Washington Fair Credit Reporting Act. If the Company obtains
information bearing on your credit worthiness, credit standing or credit capacity, it will be used to evaluate whether you would present an
unacceptable ri sk of theft or other dishonest beh avior in the job for which you are bei ng considere d.
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