Request for Criminal History Consumer Report

APPLICANT AUTHORIZATION TO OBTAIN INVESTIGATIVE BACKGROUND REPORT

In connection with my application for employment or promotion or other job change, I hereby instruct and authorize Guardian Angels Sitting Service (the "Company") to obtain an INVESTIGATIVE CONSUMER REPORT on me that will include information as to my character, general reputation, personal characteristics and mode of living. This report may reveal information about my work habits, including oral assessments of my job performance, experiences and abilities, along with reasons for termination of past employment. Such a report may be requested by the Company or on behalf of the Company. Further, I understand and agree that the Company and/or the below-named Consumer Reporting Agency may request information from various federal, state, and other agencies, including public and private sources which maintain records concerning my past activities relating to my driving record, credit history, criminal record, civil matters, previous employment, educational background and professional licensing, if any. This report will be ordered from the below-named Consumer Reporting Agency:



Background Investigations
1685 H Street # 1387
Blaine, WA 98230
(888) 338-1550
http://www.wedobackqroundchecks.com

APPLICANT'S PERSONAL INFORMATION:

First Name
Middle Name
Last Name

Other names used and dates of use:

Full Name 1

Dates 1

Full Name 2

Dates 2

Full Name 3

Dates 3

 




Social Security Number*
Drivers License#
State

Birthdate*

Place of Birth*

 





Height*
Weight*
Hair Color*

Eye Color*
Gender*
Race*

 



Have you been convicted of a crime?
NoYes

 

If "yes", please give details (date, crime, location).

 




List addresses, cities, states and counties of residence you have lived for the past seven years.:

Address
From
To

Address
From
To

Address
From
To

 



DISCOLURES TO UNDERSIGNED APPLICANT

This is written notice from the Company that an investigative consumer report is being obtained from a consumer reporting agency(CRA) for employment purposes. The undersigned applicant hereby instructs, authorizes and requests any present or former employer, school, police department, financial institutions, division of motor vehicles, or other persons or agencies having personal knowledge about the undersigned applicant to furnish the above-named Consumer Reporting Agency with any and all information in their possession regarding the undersigned applicant, in connection with an application for employment. The undersigned applicant hereby instructs, authorizes and requests that a photocopy of this authorization be accepted with the same authority as the original.


Under the federal Fair Credit Reporting Act (FCRA) and other applicable state law, you have certain rights with regard to consumer reports obtained for employment purposes including, upon request, disclosure of information on you in the reporting agency’s file at the time of request including the identification of persons who have procured a consumer report concerning you, and reasonable opportunity to respond to any information in the report that is disputed by you. The FCRA, 15 U>S>C 1681, is designed to promote accuracy, fairness, and privacy of information in the files of every “consumer reporting agency” (CRA). You can obtain a copy of any investigative consumer report obtained by Background Investigation, Inc., PO Box 3366, Lynnwood, WA 98046-3366.


If a consumer investigative report is obtained and an adverse decision is made affecting your employment, the Company will provide you to you, before making the adverse decision, a copy of the investigative consumer report and a copy of the Federal Trade Commission Publication, A Summary of Your Rights Under the Fair Credit Reporting Act.


The undersigned applicant hereby acknowledges that he/she (i) has read or has had read to him/her the above authorization and disclosures, (ii) has understood it, (iii) had the opportunity to consult with and discuss this form with his/her attorney prior to signing this document, and (iv) agrees to be fully bound by it.

 

Applicant Consent:

Date Consent Given: