Consent to Background Check

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									This agreement is used by employers to obtain consent from a potential employee to
conduct a thorough background check. This background check includes a consumer
credit check, a criminal background check, verification of credentials, DMV checks, and
Social Security Number verification. This agreement can be modified by users in
California, Massachusetts, New York and Maryland to add specific additional consent
provisions pursuant to state law. This document should be used by small businesses or
other entities that wish to conduct a thorough background check of potential employees.

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                        [Instruction: Insert company logo/letterhead here.]

                                 Consent to Background Check

(Please read and sign this form in the space provided below. Your written authorization is
necessary for completion of the application process.)
I, ____________, [Instruction: Insert person’s name.] hereby authorize _____ [Instruction:
Insert company name.] (“Company”) to investigate my background and qualifications for
purposes of evaluating whether I am qualified for the position for which I am applying
[Comment: If background check is for other than employment purposes, revise as
applicable.]. I understand that Company will utilize an outside firm or firms to assist it in
checking such information, and I specifically authorize such an investigation by information
services and outside entities of the Company's choice, in its sole discretion. I understand such
background investigations may include obtaining any or all of the following: (i) credit reports;
(ii) verification of education, degrees, certifications, work experience, work record, educational
transcripts, skills, and other information which bears on my characteristics; (iii) DMV checks
(including driving record history); (iv) criminal background information; (v) civil litigation
background; (vi) Social Security Number Verification (vii) other information which bears on my
credit, general reputation, personal characteristics, and/or mode of living where permitted and
I understand that I may at any time withhold my permission to investigate my background and
qualifications and that in such a case, no investigation will be done, and my application for
employment will not be processed further. In such instance, I may be ineligible for employment
with Company.
[Optional language: I have received, reviewed, and understand the notices attached hereto
consisting of notice explaining my rights under applicable state and federal law relating to
consumer reports and investigative consumer reports.]

[Optional Language Applicable in California: You may view the file maintained on you, if
any, by the background check vendor during normal business hours. You may also obtain
a copy of this file upon submitting proper identification and paying the costs of duplication
services, by appearing at the background check vendor’s offices in person, during normal
business hours and on reasonable notice, or by mail; you may also receive a summary of
the file by telephone. If you appear in person, you may be accompanied by one other
person, provided that person furnishes proper identification. You are advised that the
consumer report or investigative consumer reports obtained may include information
about your character, general reputation, personal characteristics, and mode of living.
Comment: The 1st sentence should include a check box to indicate that the potential
employee has the right to indicate whether or not he or she would like a copy of the file.
The Disclosure and Authorization form also must identify the name of the consumer
reporting agency. Second, the form must identify the nature and scope of the background
check. Third, it must summarize the provisions of California Civil Code § 1786.22, which
addresses how a consumer may find out what is located in a background screening
company’s file. Cal. Civ. Code § 1786.16]

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[Optional Language Applicable in New York: You have the right, upon written request, to be
informed of whether or not a consumer report was requested. If a consumer report is
requested, you will be provided with the name and address of the consumer reporting
agency furnishing the report. When New York potential employers order investigative
consumer reports regarding applicants or employees’ criminal history, they must provide a
copy of New York Correction Law Article 23-A to the consumer. N.Y. Gen. Bus. Law §§
380-c, 380-g. To reduce the chance that an individual could later claim that he did not
receive this statutorily-required form, employers may ask an individual to acknowledge
that he or she received Article 23-A in the Disclosure and Authorization form.]

[Optional Language Applicable in Massachusetts: You are advised that the consumer report
or investigative consumer reports obtained may include information about your character,
general reputation, personal characteristics, and mode of living.]

[Optional Language Applicable in Maryland: You are advised that any reports of a nature
regarding credit, if applicable and if any, will only be obtained, reviewed, used and
maintained by Company in accordance with applicable state and federal law. Comment:
Prior to obtaining any such credit reports, potential employer should ensure it is in
compliance with the recently enacted Maryland law (passed April 12, 2011) regarding
__________________________________       __________________
Applicant’s Signature                    Date
Applicant’s Name-Printed

© Copyright 2012 Docstoc Inc.                                                  3

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