DISCLOSURE STATEMENT/AUTHORIZATION TO OBTAIN A CONSUMER REPORT
DISCLOSURE/AUTHORIZATION STATEMENT
By this document,_______________ (“the Company”), discloses to prospective tennants and applicants for employment that a consumer report may be obtained prior to a rental/lease agreement, anticipated promotion, demotion or transfer to another position within the Company or, for employment purposes as part of the pre-employment background investigation. The Company will comply with provisions of public law 91-508 (Fair Credit Reporting Act) as specified in the permissible purposes section of this law. A consumer report requested by _______________ is for _____________ exclusive use and will not be resold or distributed; and that ___________ agrees to identify the permissible purpose for each request to the credit bureau. The following are recognized, business-related reasons, for which ____________ will need to obtain the consumer reports on current employees, applicants and tennants: (a) For determining job applicants’ suitability for employment purposes, insofar as ____________ employees have access to sensitive account and credit information of customers or,
(b)
In connection with a business transaction involving the consumer; and the applicant agrees to certify the legitimate business need for such a report when ordered
Reports on employees will be requested only by the Company’s designated representatives. Employees will be forbidden to obtain reports on themselves, associates or any other person except in the exercise of their official duties. Public law 91-508 provides that any person who knowingly and willfully obtains information on a consumer from a consumer reporting agency under false pretenses shall be fined not more than $5,000.00 or imprisoned fo r not more than one year or both.
In connection with my release for credit reports I have rights as defined under The Fair Credit Reporting Act. A summary of these rights which are attached to this document can also be found in the complete text of the FCRA,15 U.S.C 1681-1681u, at the FCRA web site http://www.ftc.gov. It is understood that should there be any adverse action based solely on or in part of this report I have a right to a copy of this report and, Upon written receipt of notice to challenge such report (within 30 days), I will be provided with the names and toll free phone numbers of the reporting agencies. It is further understood that I may have further rights under State law and may wish to contact a State or Local consumer protection agency. I,_________________________, hereby authorize ___________________________ to obtain a credit report on behalf of ___________________. I further authorize ___________________ to forward a copy of these and any reports to _______________ Should there be any adverse action based solely on or in part of this report I agree to hold harmless any and all parties of _________________________ and _________________.. I am fully aware of all my rights regarding the use and dissemination of these reports as clearly stated above.
Please sign below to signify receipt of the foregoing disclosure.
Applicant Signature/Date/Social Security Number/Date of Birth ________________________________________________________
HR Signature/Date
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