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Background Investigation Form

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					This Background Investigation Form is an authorization agreement signed by an
individual giving consent for the collection and verification of data and references
provided to the authorized party. Background checks are most often used to verify
references and information pertaining to a candidate for employment. The information
or references that can be verified are related to the individual’s previous employment,
character references, credit history, criminal history, and educational qualifications. This
authorization can be modified for use by a company during its hiring phase or by
prospective landlords or other parties seeking to gather information about an individual.
                         NOTICE REGARDING OBTAINING A CONSUMER REPORT
                                   OR AN INVESTIGATIVE REPORT

Company will perform a background check of criminal and social security records for purposes of evaluating your
fitness for a position with Company. Even though we will not be conducting what is commonly understood to be
a credit check or investigation, our request for criminal and social security records might be considered a
“consumer report” or “investigative consumer report” under a law called the Fair Credit Reporting Act.
Consequently, Company must provide the attached notices and information regarding your rights in order to
comply with the Act.

Pursuant to the Fair Credit Reporting Act, 15 U.S.C. § 1681 et seq., you are hereby advised that in order to
evaluate your qualifications for the position for which you have applied, Company may request a consumer report
or an investigative consumer report. The report may include inquiries regarding your credit worthiness, credit
standing, credit capacity, character, driving record, general reputation, personal characteristics and mode of living.
Company may request an investigative consumer report, which means the foregoing information may be obtained
through personal interviews with neighbors, friends, associates or others who may have knowledge concerning
this information. Any report obtained will be used only for employment purposes and will not be used in
violation of any applicable state or federal equal employment opportunity laws.

If Company requests an investigative consumer report, you have the rights to request and receive additional
disclosures regarding the nature and scope of the investigation requested. You must make your request in writing
within a reasonable period of time after you receive this notice. If you request the additional disclosures, we will
mail them to you in writing by the latter of (1) five days after we receive your written request or (2) the date we
first request an investigative consumer report. For California applicants only, if you would like to receive a copy
of the investigative report, if one is obtained, please check appropriately below and Company will send a copy to
you within three days of receipt of such report.

NOTE: AGAIN, PLEASE NOTE THAT THIS BACKGROUND CHECK IS INTENDED ONLY TO OBTAIN
CRIMINAL AND SOCIAL SECURITY RECORDS AND IS NOT INTENDED TO OBTAIN ANY
INFORMATION REGARDING YOUR CREDIT OR FINANCIAL HISTORY OR AFFAIRS.

Employee Records Representative: __________________________                    Date: _________________

                              CONSENT TO OBTAINING CONSUMER REPORT OR
                                   INVESTIGATIVE CONSUMER REPORT

I acknowledge receipt of the foregoing NOTICE REGARDING OBTAINING A CONSUMER REPORT OR AN
INVESTIGATIVE CONSUMER REPORT and “A Summary of Your Rights Under the Fair Credit Reporting
Act.” I consent and authorize Company to obtain a consumer report and/or an investigative consumer report for
use in making a decision regarding my application for an employment position with Company.


_________________________________                                __________________________________
Applicant Signature                                              Date


_________________________________                                __________ - _________ - ____________
Printed Name of Applicant                                        Social Security Number

 I am a California Resident.
 Send me copy of investigative report, if obtained. (CA residents)



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DOCUMENT INFO
Description: This Background Investigation Form is an authorization agreement signed by an individual giving consent for the collection and verification of data and references provided to the authorized party. Background checks are most often used to verify references and information pertaining to a candidate for employment. The information or references that can be verified are related to the individual’s previous employment, character references, credit history, criminal history, and educational qualifications. This authorization can be modified for use by a company during its hiring phase or by prospective landlords or other parties seeking to gather information about an individual.