Background Screeners of America · 18344 Oxnard St. Suite 101
Tarzana, CA 91356 · 866-570-4949 · FAX 866-570-5656 · info@wescreenusa.com

DISCLOSURE AND RELEASE FORM

In connection with my application for employment (including contract for services or volunteer services) or tenancy with Workforce Brokers /Workforce Solutions, at 9 S Peachtree St, Norcross, Georgia 30071, consumer reports will be requested. These consumer reports (investigative consumer reports in California) may include the following types of information: names and dates of previous employers, salary, work experience, education, accidents, licensure, credit (except California), etc. I further understand that such reports may contain public record information such as, but not limited to: my driving record, workers’ compensation claims, judgments, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records.

In addition, investigative consumer reports as defined by the federal Fair Credit Reporting Act, gathered from personal interviews with former employers and other past or current associates of mine to gather information

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THE CONSUMER
REPORTING AGENCY TO FURNISH THE ABOVE-MENTIONED INFORMATION.

I have the right to make a request to the consumer reporting agency: Background Screeners of America, 18344 Oxnard Street, Suite 101, Tarzana, CA 91356; telephone (866) 570-4949) ("Agency"), upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information and the agency, on our behalf, will provide a complete and accurate disclosure of the nature and scope of the investigation covered by the investigative consumer report(s); and the recipients of any reports on me which the agency has previously furnished within the two year period for employment requests, and one year for other purposes preceding my request (California three years). I hereby consent to your obtaining the above information from the agency. You may view their privacy policy at their website: www.backgroundscreenersofamerica.com. I hereby authorize procurement of consumer report(s) and investigative consumer report(s). If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.

California, Minnesota and Oklahoma Applicants only: Check box if you request a copy of any consumer report ordered on you.

Notice to California Applicants:

You have the right under Section 1786.22 of the California Civil Code to contact the Agency during reasonable hours (9:00 a.m. to 5:00 p.m. (PTZ) Monday through Friday) to obtain all information in your file for your review. You may obtain such information as follows: 1) In person at the Agency’s offices, which address is listed above. You can have someone accompany you to the Agency’s offices. Agency may require this third party to present reasonable identification. You may be required at the time of such visit to sign an authorization for Agency to disclose to or discuss your information with this third party; 2) By certified mail, if you have previously provided identification in a written request that your file be sent to you or to a third party identified by you; 3) By telephone, if you have previously provided proper identification in writing to Agency; and 4) Agency has trained personnel to explain any information in your file to you and if the file contains any information that is coded, such will be explained to you.

Notice to New York Applicants:

For consumers applying for work in New York: I acknowledge receiving a copy of Article 23-A of the New York Correction Law . (Initials)

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I acknowledge I have been provided a copy of consumer’s rights under the Fair Credit Reporting Act.


Current Address: Previous Address:
Alias Names Used:
 
APPLICANT SIGNATURE
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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 credit-worthiness 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 1-888-567-8688.

  • 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.

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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. For information about your federal rights, contact:

TYPE OF BUSINESS:

CONTACT:

  1. Banks, savings associations, and credit unions with total assets of

    over $10 billion and their affiliates.

  2. Such affiliates that are not banks, savings associations, or credit

    unions also should list, in addition to the Bureau:

  1. Bureau of Consumer Financial Protection

    1700 G Street NW

    Washington, DC 20006

  2. Federal Trade Commission: Consumer Response Center -FCRA

    Washington, DC 20580

    (877) 382-4357

2. To the extent not included in item 1 above:


  1. National banks, federal savings associations, and federal branches

    and federal agencies of foreign banks

  2. State member banks, branches and agencies of foreign banks (other

    than federal branches, federal agencies, and insured state branches of

    foreign banks), commercial lending companies owned or controlled

    by foreign banks, and organizations operating under section 25 or

    25A of the Federal Reserve Act

  3. Nonmember Insured Banks, Insured State Branches of Foreign

    Banks, and insured state

  1. Office of the Comptroller of the Currency

    Customer Assistance Group

    1301 McKinney Street, Suite 3450

    Houston, TX 77010-9050

  2. Federal Reserve Consumer Help Center

    P.O. Box 1200

    inneapolis, MN 55480

  3. FDIC Consumer Response Center

    1100 Walnut Street, Box #11

    Kansas City, MO 64106

  4. National Credit Union Administration

    Office of Consumer Protection (OCP)

    Division of Consumer Compliance and Outreach (DCCO)

    1775 Duke Street

    Alexandria, VA 22314

3. Air carriers

Asst. General Counsel for Aviation Enforcement & Proceedings

Department of Transportation

400 Seventh Street SW

Washington, DC 20590

4. Creditors Subject to Surface Transportation Board

Office of Proceedings, Surface Transportation Board

Department of Transportation

1925 K Street NW

Washington, DC 20423

5. Creditors Subject to Packers and Stockyards Act

Nearest Packers and Stockyards Administration area supervisor

6. Small Business Investment Companies

Associate Deputy Administrator for Capital Access

United States Small Business Administration

406 Third Street, SW, 8th Floor

Washington, DC 20416

7. Brokers and Dealers

Securities and Exchange Commission

100 F St NE Washington,

DC 20549

8. Federal Land Banks, Federal Land Bank Associations, Federal

Intermediate Credit Banks, and Production Credit Associations

Farm Credit Administration

1501 Farm Credit Drive

McLean, VA 22102-5090

9. Retailers, Finance Companies, and All Other Creditors Not Listed Above

FTC Regional Office for region in which the creditor operates or

Federal Trade Commission: Consumer Response Center - FCRA

Washington, DC 20580

(877) 382-4357

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