Sample Stand-Alone Disclosure Form this document is intended for instructional purposes only and is not intended as legal advice. We recommend you consult


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NameSample Stand-Alone Disclosure Form this document is intended for instructional purposes only and is not intended as legal advice. We recommend you consult
A typeDocumentation
DISCLAIMER: Sample Stand-Alone Disclosure Form – this document is intended for instructional purposes only and is not intended as legal advice. We recommend you consult with an attorney to review this document to ensure your compliance with the Fair Credit Reporting Act (15 U.S.C. § 1681) and applicable state laws related to background screening.
NOTICE TO APPLICANT/EMPLOYEE REGARDING BACKGROUND INVESTIGATION
In connection with your application for employment or continuing employment, notice is hereby given that a consumer report and/or investigative consumer report may be obtained from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or “investigative consumer report” as defined by the Fair Credit Reporting Act (15 U.S.C. § 1681). These reports may contain information about your character, general reputation, personal characteristics and mode of living, whichever are applicable. They may involve personal interviews with sources such as your neighbors, friends or associates. The reports may also contain information about you relating to your criminal history, credit history, driving and/or motor vehicle records, social security verification, education or employment history, or other background checks.
You have the right, upon written request made within a reasonable time after the receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report prepared by contacting us and First Advantage, P.O. Box 3367, Seminole, FL 33775-3367; 1-800-321-4473 ext. 8. Information about First Advantage’s privacy practices can be reviewed at: http://www.fadv.com/Privacy-Policy.aspx.

DISCLAIMER: Sample Stand-Alone Authorization Form – this document is intended for instructional purposes only and is not intended as legal advice. We recommend you consult with an attorney to review this document to ensure your compliance with the Fair Credit Reporting Act (15 U.S.C. § 1681) and applicable state laws related to background screening.

AUTHORIZATION BY APPLICANT/EMPLOYEE TO CONDUCT BACKGROUND INVESTIGATION
By signing below, you acknowledge receipt of the Notice to Applicant/Employee Regarding Background Investigation and certify that you have read this disclosure. Furthermore, you authorize the obtaining of consumer reports and/or investigative consumer reports at any time after receipt of this authorization and throughout the course of your employment, if applicable.
The scope of the Notice to Applicant/Employee Regarding Background Investigation and your authorization is not limited to the present and, if you are hired, will continue throughout the course of your employment and allow us to conduct future screenings for retention, promotion or reassignment, as permitted by law and unless revoked by you in writing.
Print Full Name: ___________________________________________________

Signature: ________________________________________________________

Date: _______________________
Street Address: ____________________________________________________

City: ______________________ State: ___________ Zip: _________________

DISCLAIMER: Sample State Disclosure Forms – these documents are intended for instructional purposes only and are not intended as legal advice. We recommend you consult with an attorney to review these documents to ensure your compliance with state consumer protection laws related to background screening.
STATE DISCLOSURES – BACKGROUND INVESTIGATION
Pursuant to state law, the following disclosures are provided to state residents.
CALIFORNIA applicants or employees only: By signing below, you acknowledge receipt of the NOTICE – BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check the box if you would like to receive a copy of the investigative consumer report or consumer credit report, free of charge, if one is obtained by us.
Check box to receive report □
NEW YORK applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by us by contacting First Advantage, P.O. Box 3367, Seminole, FL 33775-3367; 1-800-321-4473 ext. 8.
NEW YORK applicants or employees only: By signing below, you acknowledge receipt of a copy of Article 23-A of the New York Correction Law.
WASHINGTON applicants or employees only: You have the right to request from First Advantage, P.O. Box 3367, Seminole, FL 33775-3367; 1-800-321-4473 ext. 8, a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
MASSACHUSETTS, MINNESOTA and OKLAHOMA applicants or employees only: Please check the box if you would like to receive a copy of your consumer report, free of charge, if one is obtained by us.
Check box to receive report □
Print Full Name: ___________________________________________________

Signature: ________________________________________________________

Date: _______________________

NOTICE – BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW
California Residents or Employees – this summary of the provisions of California Civil Code section 1786.22 is being provided to you pursuant to state law.
Your employer intends to obtain information about you from an investigative consumer reporting agency, as defined under California law, for employment purposes.
Under California law you are entitled to visually inspect all files maintained about you by an investigative consumer reporting agency (ICRA), such as First Advantage, P.O. Box 3367, Seminole, FL 33775-3367; 1-800-321-4473 ext. 8, upon request and presentation of proper identification during normal business hours and on reasonable notice as follows:


  • In person. You may request a copy of your file. The ICRA may charge you for the actual copying costs associated with providing you with a copy of your file.

  • By telephone. A summary of all information contained in the ICRA’s file about you will be provided to you via telephone, if you have made a written request for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to you.

  • By certified mail. You may make a written request for copies to be sent to a specified addressee. ICRA’s 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 ICRA.


“Proper Identification” includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. If an ICRA is unable to reasonably identify you on the basis of these documents, they may 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.

NOTICE – BACKGROUND INVESTIGATION AND

USE OF CREDIT INFORMATION PURSUANT TO CALIFORNIA LAW
California Residents or Employees – this summary of the provisions of California Civil Code section 1785.20.5 is being provided to you pursuant to state law.

Prior to requesting a consumer credit report for employment purposes, the user of the report shall provide written notice to the person involved. The notice shall inform the person that a report will be used, and shall identify the specific basis under subdivision (a) of Section 1024.5 of California’s Labor Code for use of the report. The notice shall also inform the person of the source of the report, and shall contain a box that the person may check off to receive a copy of the credit report. If the consumer indicates that he or she wishes to receive a copy of the report, the user shall request that a copy be provided to the person when the user requests its copy from the credit reporting agency. The report to the user and to the subject person shall be provided contemporaneously and at no charge to the subject person.

California Labor Code section 1024.5 is provided below:

1024.5. (a) An employer or prospective employer shall not use a consumer credit report for employment purposes unless the position of the person for whom the report is sought is any of the following:

(1) A managerial position.

(2) A position in the state Department of Justice.

(3) That of a sworn peace officer or other law enforcement position.

(4) A position for which the information contained in the report is required by law to be disclosed or obtained.

(5) A position that involves regular access, for any purpose other than the routine solicitation and processing of credit card applications in a retail establishment, to all of the following types of information of any one person:

(A) Bank or credit card account information.

(B) Social security number.

(C) Date of birth.

(6) A position in which the person is, or would be, any of the following:

(A) A named signatory on the bank or credit card account of the employer.

(B) Authorized to transfer money on behalf of the employer.

(C) Authorized to enter into financial contracts on behalf of the employer.

(7) A position that involves access to confidential or proprietary information, including a formula, pattern, compilation, program, device, method, technique, process or trade secret that (i) derives independent economic value, actual or potential, from not being generally known to, and not being readily ascertainable by proper means by, other persons who may obtain economic value from the disclosure or use of the information, and (ii) is the subject of an effort that is reasonable under the circumstances to maintain secrecy of the information.

(8) A position that involves regular access to cash totaling ten thousand dollars ($10,000) or more of the employer, a customer, or client, during the workday.

(b) This section does not apply to a person or business subject to Sections 6801 to 6809, inclusive, of Title 15 of the United States Code and state and federal statutes or regulations implementing those sections if the person or business is subject to compliance oversight by a state or federal regulatory agency with respect to those laws.

(c) The following definitions apply to this section:

(1) "Consumer credit report" has the same meaning as defined in subdivision (c) of Section 1785.3 of the Civil Code, but does not include a report that (A) verifies income or employment, and (B) does not include credit-related information, such as credit history, credit score, or credit record.

(2) "Managerial position" means 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 (8 Cal. Code Regs. 11040).

NOTICE – BACKGROUND INVESTIGATION PURSUANT TO NEW JERSEY LAW
New Jersey Residents or Employees – this summary of the provisions of the New Jersey Fair Credit Reporting Act (NJFCRA) is being provided to you pursuant to state law (N.J.S.A. § 56:11-28 et seq.)


  • Before an employer can obtain a consumer report about you from a consumer reporting agency they must provide you with a clear and conspicuous disclosure in writing that such may be obtained for employment purposes. You must provide written consent to the procurement, for employment purposes, of a consumer report.



  • When using a consumer report for employment purposes, before taking adverse action based in whole or in part on the report, an employer must provide you with a copy of the consumer report and a description in writing of your rights under the federal Fair Credit Reporting Act as well as the NJFCRA.




  • You must be afforded a reasonable opportunity to dispute, with the consumer reporting agency, any information on which the employer relied upon in your consumer report.



  • You can request from a consumer reporting agency all information in your file, upon proper identification. This includes sources of information and identification of each person who procured a consumer report for employment purposes during the two-year period preceding your request. These requests must be made during normal business hours and on reasonable notice. It can be done in person or by telephone, if you have made a written request and pay the toll charge. A consumer reporting agency must provide trained personnel to explain to you any information in the consumer report.



  • You can dispute inaccurate information with the consumer reporting agency. If you dispute the completeness or accuracy of any of the information in your file, the consumer reporting agency must reinvestigate free of charge during a 30-day period. A consumer reporting agency must provide written notice to you of the results of the reinvestigation not later than five business days after completion of the reinvestigation.




  • If, after a reinvestigation, any information disputed by you is found to be inaccurate or incomplete or cannot be verified, the consumer reporting agency must promptly delete that item of information from your file or modify that item of information, as appropriate, based on the results of the reinvestigation.



  • You can seek damages for noncompliance under the NJFCRA.

NOTICE – BACKGROUND INVESTIGATION PURSUANT TO NEW YORK LAW
New York Residents or Employees – this summary of the provisions of the New York Correction Law is being provided to you pursuant to state law.
Article 23-A

Licensure and Employment of Persons Previously

Convicted of One or More Criminal Offenses
§ 750. Definitions
For the purposes of this article, the following terms shall have the following meanings:
(1) “Public agency” means the state or any local subdivision thereof, or any state or local department, agency, board or commission.
(2) “Private employer” means any person, company, corporation, labor organization or association which employs ten or more persons.
(3) “Direct relationship” means that the nature of criminal conduct for which the person was convicted has a direct bearing on his fitness or ability to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in question.
(4) “License” means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions or instrumentalities as a condition for the lawful practice of any occupation, employment, trade, vocation, business, or profession. Provided, however, that “license” shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire any explosive, pistol, handgun, rifle, shotgun, or other firearm.
(5) “Employment” means any occupation, vocation or employment, or any form of vocational or educational training. Provided, however, that “employment” shall not, for the purposes of this article, include membership in any law enforcement agency.
§ 751. Applicability
The provisions of this article shall apply to any application by any person for a license or employment at any public or private employer, who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any license or employment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdiction preceded such employment or granting of a license, except where a mandatory forfeiture, disability or bar to employment is imposed by law, and has not been removed by an executive pardon, certificate of relief from disabilities or certificate of good conduct. Nothing in this article shall be construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with an application for employment made by a prospective employee or previously made by a current employee.
§ 752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited
No application for any license or employment, and no employment or license held by an individual, to which the provisions of this article are applicable, shall be denied or acted upon adversely by reason of the individual's having been previously convicted of one or more criminal offenses, or by reason of a finding of lack of “good moral character” when such finding is based upon the fact that the individual has previously been convicted of one or more criminal offenses, unless:
(1) there is a direct relationship between one or more of the previous criminal offenses and the specific license or employment sought or held by the individual; or
(2) the issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk to property or to the safety or welfare of specific individuals or the general public.
§ 753. Factors to be considered concerning a previous criminal conviction; presumption
1. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall consider the following factors:
(a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons previously convicted of one or more criminal offenses.
(b) The specific duties and responsibilities necessarily related to the license or employment sought or held by the person.
(c) The bearing, if any, the criminal offense or offenses for which the person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities.
(d) The time which has elapsed since the occurrence of the criminal offense or offenses.
(e) The age of the person at the time of occurrence of the criminal offense or offenses.
(f) The seriousness of the offense or offenses.
(g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct.
(h) The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of specific individuals or the general public.
2. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein.
§ 754. Written statement upon denial of license or employment
At the request of any person previously convicted of one or more criminal offenses who has been denied a license or employment, a public agency or private employer shall provide, within thirty days of a request, a written statement setting forth the reasons for such denial.
§ 755. Enforcement
1. In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to article seventy-eight of the civil practice law and rules.
2. In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights pursuant to the powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city commission on human rights.


8360840v1

Revised: 12/9/15

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