Application Disclosure and Applicant Release for Consumer and Investigative Consumer Reports

In connection with my application for employment with ____________ , I understand that a consumer report (and/or investigative consumer report), as defined by the Fair Credit Reporting Act (FCRA), may be obtained for employment purposes.

Applicant Signature _ ________________ Date ________ _

I, _________ am the parent or guardian of the applicant. I have reviewed this disclosure with my child/ward and have had an opportunity to have a meaningful consultation with him/ her regarding this disclosure and its implications. I am executing this document on behalf of my child/ward and with his/her permission.

Parent/Guardian Signature ________________ Date _______ _

APPLICANT RELEASE FOR CONSUMER AND INVESTIGATIVE CONSUMER REPORTS

I authorize all corporations, employers, co-workers, references, credit reporting agencies, educational institutions, licensing bodies, courts, law enforcement agencies, governmental agencies or departments, and military services to provide information about my background, including but not limited to driving records, court records, workers compensation records, credit report, academic records, professional license record and employment related information or records. I agree to release the aforesaid from any liability for collecting that information.

I understand that an investigative consumer report is a special type of consumer report that is obtained through interviews and may contain information about my character, general reputation, personal characteristics, and/or mode of living. Upon my written request within a reasonable period of time, a complete disclosure of the nature and scope of that investigation will be made to me in writing within five days of the date on which the request was received.

I further authorize ___________ to request a consumer report and/or investigative consumer report about me, for employment related purposes, at any time to the extent allowed by law. I agree that this Disclosure and Release will be valid, now or in the future, in original, faxed, copied or electronic form.

I acknowledge that I have received a copy of the “Summary of Your Rights Under the Fair Credit Reporting Act.”

I understand that my date of birth will be used solely for identification purposes.

First Name ___________ Full Middle _____ Last. _ ________ Suffix. ____ _
Any other name(s) used. _______________________________ _
Social Security # __________________ Date of Birth ___________ _
Position Applied For __________________________________ _
Present Address, __________________________________ _
City/State/Zip/County _________________________ _______ _
Telephone Number(s) ________ Email Address. ___________________ _
Previous Cities/States/ZipCodes/Counties of Residence During Last 7 Years. ______________ _
Driver’s License# _____ _____________ State of Issuance. _________ _

I, __________ am the parent or guardian of the applicant. I have reviewed these authorizations and
releases with my child/ward and have had an opportunity to have a meaningful consultation with him/ her regarding these
authorizations and releases and their implications. I am executing this document on behalf of my child/ward and with his/her
permission. I furthermore authorize my child/ward to execute all authorizations and releases contained herein having had an
opportunity to have a meaningful consultation with him/her about the authorizations and releases and their implications.

Parent/Guardian Signature ____________________ Date _________ _
Applicant Signature ______________________ Date _________ _

California, Minnesota, and Oklahoma residents only:
Please initial here only if you are requesting a copy of the consumer report prepared on you ____ _

Para informacion en espanol, visite www.consumerfinance.gov/learnmore o escribe a la Consumer
Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G
Street N.W., Washington, DC 20552.

• You must be told if information in your file has been used against you. Anyone who uses a credit
  report or another type of consumer report to deny your application for credit, insurance, or employment
  – or to take another adverse action against you – must tell you, and must give you the name, address,
  and phone number of the agency that provided the information.
• You have the right to know what is in your file. You may request and obtain all the information about
  you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide
  proper identification, which may include your Social Security number. In many cases, the disclosure will
  be free. You are entitled to a free file disclosure if:
  • a person has taken adverse action against you because of information in your credit report;
    you are the victim of identity theft and place a fraud alert in your file;
  • your file contains inaccurate information as a result of fraud;
  • you are on public assistance;
  • you are unemployed but expect to apply for employment within 60 days.

  In addition, all consumers are entitled to one free disclosure every 12 months upon request from each
  nationwide credit bureau and from nationwide specialty consumer reporting agencies. See
  www.consumerfinance.gov/learnmore for additional information.

  • You have the right to ask for a credit score. Credit scores are numerical summaries of your creditworthiness
    based on information from credit bureaus. You may request a credit score from consumer
    reporting agencies that create scores or distribute scores used in residential real property loans, but
    you will have to pay for it. In some mortgage transactions, you will receive credit score information for
    free from the mortgage lender.
  • You have the right to dispute incomplete or inaccurate information. If you identify information in
    your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency
    must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an
    explanation of dispute procedures.
  • Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable
    information. Inaccurate, incomplete or unverifiable information must be removed or corrected,
    usually within 30 days. However, a consumer reporting agency may continue to report information
    it has verified as accurate.
  • Consumer reporting agencies may not report outdated negative information. In most cases, a
    consumer reporting agency may not report negative information that is more than seven years old, or
    bankruptcies that are more than 10 years old.
  • Access to your file is limited. A consumer reporting agency may provide information about you only
    to people with a valid need — usually to consider an application with a creditor, insurer, employer,
    landlord, or other business. The FCRA specifies those with a valid need for access.
  • You must give your consent for reports to be provided to employers. A consumer reporting agency
    may not give out information about you to your employer, or a potential employer, without your written
    consent given to the employer. Written consent generally is not required in the trucking industry. For
    more information, go to www.consumerfinance.gov/learnmore.
  • You may limit “prescreened” offers of credit and insurance you get based on information in your
    credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone
    number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).
  • You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of
    consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you
    may be able to sue in state or federal court.
  • Identity theft victims and active duty military personnel have additional rights. For more
    information, visit www.consumerfinance.gov/learnmore.

  States may enforce the FCRA, and many states have their own consumer reporting laws. In some
  cases, you may have more rights under state law. For more information, contact your state or local
  consumer protection agency or your state Attorney General.