DISCLOSURE OF INTENT TO OBTAIN CONSUMER REPORTS OR INVESTIGATIVE CONSUMER REPORTS AND RELEASE AUTHORIZATION
For employment purposes, Jackson Therapy Partners and/or its related entities or agents (collectively referred to herein as the “Company”) may obtain consumer reports, or investigative consumer reports, in connection with your employment application or from time to time during employment in accordance with applicable law. Consumer reports include record checks conducted by consumer reporting agencies and may include driving records, criminal records, credit records, etc. Investigative consumer reports include investigations (for example, reference checks) conducted by consumer reporting agencies through personal interviews or any means on information as to character, general reputation, personal characteristics, or mode of living. You may make a written request for a summary of consumer rights and a disclosure of the nature and scope of an investigation. A disclosure of the nature and scope of such investigation is provided below. In the event the Company requests an investigative consumer report in connection with your employment application, existing employment with the Company or other inquiry, a consumer reporting agency or other person or entity (collectively referred to herein as “agency”) may prepare an investigative consumer report that may be based on the following investigation: The agency may interview your former employers, business references, and/or personal references for information regarding prior employment, work experience and performance, reasons for employment termination, and information as to character, general reputation, personal characteristics, or mode of living. The agency may also conduct a records check of driving, criminal, credit, education, degrees, professional licenses, and/ or certification records depending on the position.
AUTHORIZATION
I hereby authorize the Company to obtain consumer reports and/or investigative consumer reports regarding me from time to time for purposes relating to employment. I further authorize the Company or its agents to release to third parties any information, documents or assessments regarding me, including my performance as an employee, student, associate or acquaintance, obtained pursuant to this authorization or otherwise in the Company’s possession. I authorize that a photocopy or electronic facsimile of this document shall serve as an original. I understand that I may have a right to request in writing information regarding the nature and scope of any investigative report prepared on me. Print Name: __________________________ Date of Birth: ______________ Soc. Sec. No.: _______________ List other names used, if applicable (including maiden name): ________________________________________ Signature: ___________________________ Date: __________ Driver’s License No.: ___________________ Name as it appears on Drivers License:_________________________ State Issuing License: ______________ Current Address: ____________________________________________________________________________ No. Street City State Zip County Length at current address: __________________ (If less than 15 years, provide previous addresses below) Prior Address: ____________________________________________________________________________ No. Street City State Zip County Length at prior address: _____ months _____ years Prior Address: ____________________________________________________________________________ No. Street City State Zip County
Length at prior address: _____ months _____ years Prior Address: ____________________________________________________________________________ No. Street City State Zip County Length at prior address: _____ months _____ years The following states require sex and race to obtain information: AL, AR, FL, GA, IA, IL, IN, OR, TX, WI Check applicable categories: __ Male __ Female __ Asian __ Black __ Hispanic __ White __ Other
California Applicants Only - - In California, if you wish to receive a free copy of any credit report obtained, please indicate by checking this box. Minnesota Applicants Only - - If you are in Minnesota and you desire a free copy of your consumer report, please place an “X” in the box. New York Applicants Only - - Upon your request, you will be informed whether or not a consumer report was requested, and if such a report was requested, the name and address of the consumer reporting agency furnishing the report.