"Background Request Form"
Notification Form Regarding Background Screening (Consumer) Report For employment purposes, we may obtain a consumer report and/or an investigative report about you. The Fair Credit and Reporting Act give you specific rights. If we rely on the report for an adverse action, before taking adverse action, we will give you a pre-adverse action disclosure that includes a copy of the consumer/investigative report about you for employment purposes and authorize all corporations, former employers, credit agencies, educational institutional institutions, law enforcement agents, city, state, county and federal courts and agencies, military services and persons to release all information they may have about you. This authorization shall be valid in original or copy form. Applicant’s Name: Social Security No.: _____________________________ Date of Birth ________________________________________ Current Street Address: City, State, Zip Code: Telephone Number: Applicant’s Signature: Date: Witness Signature: Original to Applicant and a copy for SCI Files