This sample form is provided strictly for educational purposes and

This sample form is provided strictly for educational purposes and should not be construed as legal advice, guidance or counsel. Employers and/or end users of
consumer reports should consult with their own counsel about their responsibilities under the FCRA and other applicable laws to ensure compliance and that
your needs are met. Accurate Background expressly disclaims any warranties or responsibility or damages associated with or arising out of information provided.
SAMPLE DISCLOSURE REGARDING CONSUMER AND/OR INVESTIGATIVE REPORT
The Employer, ____________________________ (“Company”) may obtain information about you for employment purposes from a third party consumer reporting
agency. 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, supervisors, 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. Further, you understand that information may be requested from various Federal, State,
County and other agencies that maintain records concerning your past activities relating to your driving, criminal, civil, education, credit, and other experiences. Credit
history will only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying.
You have the right, upon written request made within a reasonable period of time after receipt of this notice, to request whether a consumer report has been conducted
about you, disclosure of the nature and scope of any investigative consumer report, and to request a copy of your report. Please be advised that the nature and scope of
the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your employment and/or education
history. The scope of this notice and authorization is all-encompassing, however, allowing the Company to obtain consumer reports and investigative consumer reports
now and throughout the course of your employment to the extent permitted by law, unless you otherwise revoke your consent by providing written notification to
Company. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.
The consumer and/or investigative consumer report(s) will be obtained from:
Accurate Background, Inc., 7515 Irvine Center Drive, Irvine, CA 92618, (800) 216-8024.
Accurate Background’s information and privacy policy can be found at www.accuratebackground.com.
California applicants or employees only: By signing below, you also acknowledge receipt of A SUMMARY OF YOUR RIGHTS UNDER THE PROVISIONS OF CALIFORNIA CIVIL
CODE §1786.22.
Please check the appropriate box below if you would like to receive a copy of your investigative consumer report or consumer credit report at no charge.
Minnesota and Oklahoma applicants or employees only: Please check the appropriate box below if you would like to receive a copy of your consumer report free of charge.
New York applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by Company by contacting the consumer
reporting agency identified above directly. You may also contact the Company to request the name, address and telephone number of the nearest unit of the consumer reporting agency
designated to handle inquiries, which the Company shall provide within 5 days. Upon request, you will be informed whether or not a consumer report was requested by Company, and if
such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. By signing the authorization, you also acknowledge receipt of
Article 23-A of the New York Correction Law.
Oregon applicants or employees only: Information describing your rights under federal and Oregon law regarding consumer identity theft protection, the storage and disposal of your
credit information, and remedies available should you suspect or find that the Company has not maintained secured records is available to you upon request.
Washington State applicants or employees only: You also 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.
SAMPLE ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK
I acknowledge receipt of the DISCLOSURE REGARDING CONSUMER AND/OR INVESTIGATIVE REPORT 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, local, 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 Accurate Background, Inc., 7515 Irvine Center Drive,
Irvine, CA 92618 (800) 216-8024, www.accuratebackground.com, another outside organization acting on behalf of the Company, and/or the Company itself.
I understand that by signing my name below, that I am signing the Authorization form directing the background check as described above, and I certify that:


I have received the Disclosure Regarding Consumer and/or Investigative Report, have read and received the Summary of Your Rights, and if a California
resident/applicant, the A Summary of Your Rights Under the Provisions of California Civil Code §1786.22.
I understand that my signature now and throughout this process will be binding. Additionally, notices, documents, and communications may be provided
electronically and will meet the requirements set forth under Federal and/or State law, as permitted by law. I agree that a facsimile (“fax”), electronic or printout
of this authorization may be accepted with the same authority as the original.
For California, Oklahoma, or Minnesota employees and applicants: Please check the appropriate box to indicate if you would like to receive a copy of your consumer
report free of charge.
Yes
No
Print Name ___________________________________________________________________________
Other Names Known By _________________________________________________________________
Social Security Number ____-____-______
Date of Birth ___/___/_____
Driver’s License Number _______________________ State __________________
Current Address________________________________________________________________________
City________________________________________ State__________________ ZIP_______________
Applicant Signature___________________________________________________ Date______________
Prospective Employer____________________________________________________________________