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NRCS-HRM-PIA-002 09/11/06 United States Department of Agriculture Natural Resources Conservation Service FAIR CREDIT RELEASE Disclosure and Authorization Form In accordance with the Federal Fair Credit Reporting Act (Public Law 91-508, 15, U.S.C. Section 1681 ET SEQ., 604-615), all federal provisions and regulations, a credit report may be requested and obtained for employment and other exclusive purposes. Compliance by the employer with all regulations and statutes of the Fair Credit Reporting Act is required in order to obtain information. Information is requested for the exclusive use of the employer and will not be used for any other purpose than employment. By signing this release, you certify that all information provided below and on your resume is correct to the best of your knowledge. Any false statements provided in this form and your resume will be considered just cause for the termination of employment at any time. Further, you agree that a copy or facsimile of this authorization shall be as valid as the original. In addition, you release and discharge NRCS and all of its agents, any expenses, losses, damages, and liabilities for the investigative process. If your credit report is the basis for any adverse action taken against you, the agency will provide the name and contact information of the credit reporting agency (CRA) that provided the report. You must contact the CRA within 60 days of receiving notice of the adverse action. The CRA must provide you a copy of your credit report (at no cost). Applicant’s Name: ___________________________________________________________ (Please Print) First M.I. Last Social Security Number: _________ - _________ - _________ Current Address: ___________________________________________________ Street Address ___________________________________________________ City State Zip Signature: __________________________________________ Date: _____ mm/ _____ dd/ _____yy
"FAIR CREDIT RELEASE Disclosure and Authorization Form"