Background Check Authorization Form: A Guide for Employers

BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION FORM

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

IMPORTANT: PLEASE READ CAREFULLY BEFORE SIGNING

[EMPLOYER NAME] ("the Company") may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a "consumer report" and/or an "investigative consumer report" which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records ("driving records"), verification of your education or employment history, or other background checks.

This disclosure is provided to you in compliance with the Federal Fair Credit Reporting Act (FCRA) and applicable state laws. The consumer reports may be obtained for employment purposes, including but not limited to: evaluating your employment application, making decisions regarding offers of employment, and, if applicable, in connection with your continued employment, promotion, reassignment, or retention.

The scope of this disclosure and authorization is all-encompassing, allowing the Company to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law.

CONSUMER REPORTING AGENCY INFORMATION

The background check will be conducted by:

[CONSUMER REPORTING AGENCY NAME]
[STREET ADDRESS]
[CITY, STATE ZIP]
[PHONE NUMBER]
[WEBSITE]

STATE-SPECIFIC DISCLOSURES

California Applicants or Employees

Under California law, you have the right to view your file that the Consumer Reporting Agency maintains. By providing proper identification and duplication cost, you may obtain a copy of this information in person at the Consumer Reporting Agency's normal business hours and after providing reasonable notice for your request.

You can also request a copy be sent to you by certified mail upon making a written request with proper identification. The Consumer Reporting Agency can answer questions about information in your file, including any coded information. If you come in person, another person can come with you so long as they can show proper identification.

New York Applicants or Employees

You have the right, upon written request, to be informed of whether or not a consumer report was requested. If a consumer report is requested, you will be provided with the name and address of the consumer reporting agency furnishing the report.

Massachusetts Applicants or Employees

You have the right to obtain a copy of any consumer report requested by the Company by contacting the consumer reporting agency identified above.

Minnesota Applicants or Employees

You have the right, upon written request to the Consumer Reporting Agency, to receive a complete and accurate disclosure of the nature and scope of any consumer report. The Consumer Reporting Agency must make this disclosure within five days of receipt of your request or of the Company's request for the report, whichever is later.

Washington State Applicants or Employees

You 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.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the 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 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 [CONSUMER REPORTING AGENCY NAME], [CONSUMER REPORTING AGENCY ADDRESS], [CONSUMER REPORTING AGENCY PHONE NUMBER], another outside organization acting on behalf of the Company, and/or the Company itself.

I understand that by signing this authorization:

1. I authorize the Company to conduct a background check which may include, but is not limited to, information regarding my credit history, criminal history, social security verification, motor vehicle records, verification of education or employment history, or other background checks.

2. I agree that this Disclosure and Authorization form in original, faxed, photocopied, or electronic (including electronically signed) form will be valid for any reports that may be requested by or on behalf of the Company.

3. I understand that providing any false information or omitting significant information on my application materials or in interviews may be sufficient grounds for rejection of my application or immediate termination of employment.

4. I understand that I have the right to request a complete and accurate disclosure of the nature and scope of any investigative consumer report prepared on me. I understand that I may request a copy of my report, and that I may dispute the accuracy or completeness of the report by contacting the consumer reporting agency identified above.

5. I understand that before the Company takes any adverse employment action based in whole or in part on the report, I will be provided a copy of the report and a description in writing of my rights under the FCRA.

6. I understand that if I am applying for employment in California, Minnesota, or Oklahoma, I can receive a free copy of any consumer report or investigative consumer report obtained on me if I check the box below:

   □ I request a free copy of the report.

7. I understand that if the Company is located in California, Minnesota or Oklahoma, that I have the right to request a copy of my report by checking the box below:

   □ Please send me a copy of my report at the following address: ________________________________

ONGOING AUTHORIZATION

I further authorize the Company to obtain additional consumer reports and investigative consumer reports about me without asking for my authorization again, throughout my employment, to the extent permitted by applicable law, for the purpose of evaluating continued suitability for employment, promotion, reassignment, or retention as an employee.

DATA PROTECTION AND PRIVACY STATEMENT

The information collected through this background check process will be used solely for employment purposes. The Company maintains appropriate administrative, technical, and physical safeguards to protect the security and confidentiality of the information collected. Information obtained through the background check process will be retained in accordance with applicable laws and the Company's record retention policies, and will be securely destroyed when no longer needed for business or legal purposes.

For international candidates: If you are located in the European Economic Area, the United Kingdom, or another jurisdiction with comprehensive data protection laws, additional protections may apply to the processing of your personal information. The Company will process your personal information in accordance with applicable data protection laws, including obtaining your explicit consent where required.

PERSONAL INFORMATION (Please print clearly)

Full Legal Name: _______________________________________________________________ (First) (Middle) (Last)

Previous Names/Aliases (including maiden name): ____________________________________

Current Address: ______________________________________________________________ (Street) (City) (State) (ZIP)

Previous Addresses (past 7 years):

1. ---

   (Street) (City) (State) (ZIP) (Dates: From-To)

2. ---

   (Street) (City) (State) (ZIP) (Dates: From-To)

3. ---

   (Street) (City) (State) (ZIP) (Dates: From-To)

Date of Birth: //______ (For identification purposes only)

Social Security Number: -_____-

Driver's License Number: ________________________ State of Issue: _________________

Email Address: ________________________________________________________________

Phone Number: ________________________________________________________________

EMPLOYER INFORMATION

Position Applied For: ___________________________________________________________

Purpose of Background Check: □ Pre-employment (new hire) □ Promotion □ Reassignment □ Other: _____________________________________________________________________

RIGHT TO REQUEST ADDITIONAL DISCLOSURES

You have the right to request additional disclosures regarding the nature and scope of the investigation. To exercise this right, please submit a written request to [EMPLOYER CONTACT INFORMATION].

RIGHT TO OBTAIN REPORT COPY

You have the right to request and obtain a copy of any background check report secured by the Company by contacting the consumer reporting agency listed above directly.

ADVERSE ACTION NOTIFICATION PROCESS

If the Company intends to take an adverse action based in whole or in part on information contained in a consumer report, you will be provided with the following before the adverse action is taken:

1. A copy of the consumer report relied upon for the adverse action
2. A copy of "A Summary of Your Rights Under the Fair Credit Reporting Act"
3. A Pre-Adverse Action Notice explaining that the Company is considering taking adverse action
4. An opportunity to dispute the accuracy or completeness of the information in the report

After the waiting period (typically 5 business days), if the Company proceeds with the adverse action, you will receive:

1. An Adverse Action Notice stating that the adverse action has been taken
2. The name, address, and phone number of the consumer reporting agency that supplied the report
3. A statement that the consumer reporting agency did not make the decision to take the adverse action and cannot give specific reasons for it
4. A notice of your right to dispute the accuracy or completeness of any information the consumer reporting agency furnished
5. A notice of your right to an additional free consumer report from the agency upon request within 60 days

BAN-THE-BOX COMPLIANCE

The Company complies with applicable "ban-the-box" and fair chance hiring laws. Criminal history information will not be requested or considered before a conditional offer of employment is made, except where permitted by law. Any criminal history information obtained will be evaluated in accordance with applicable laws, considering factors such as the nature and gravity of the offense, the time elapsed since the offense or completion of the sentence, and the nature of the job sought.

INFORMATION RETENTION POLICY

Information obtained through the background check process will be maintained in a secure and confidential manner. The Company will retain this information for the duration of your employment plus [NUMBER] years thereafter, or as otherwise required by applicable law. After this retention period, the information will be securely destroyed in accordance with the Company's record retention policies.

NO LIABILITY WAIVER

Nothing in this authorization is intended to be or shall be construed as a waiver of your legal rights under applicable federal, state, or local laws.

SIGNATURE

By signing below, I acknowledge that I have read and understand this Disclosure and Authorization form. I authorize [EMPLOYER NAME] to obtain consumer reports and/or investigative consumer reports about me for employment purposes as described in this document.

Signature: ____________________________________________ Date: ________________

Print Name: ___________________________________________

FOR EMPLOYER USE ONLY

Requested by: _________________________________________ Date: ________________

Position: _____________________________________________