Authorization For Release of Information

 
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DISCLOSURE AND AUTHORIZATION FORM
TO OBTAIN CONSUMER REPORTS FOR EMPLOYMENT PURPOSES

Please Read Carefully Before Signing the Authorization

In considering you for employment and, if you are employed, in considering you for subsequent promotion, assignment, reassignment, retention, or discipline, ("the Company") may request and rely upon one or more consumer reports or investigative consumer reports about you that we obtain from a consumer reporting agency, such as Surveillance, Resources and Investigations, LLC.

Surveillance, Resources and Investigations. can be contacted by mail at 109 Lovett Dr; Greenville, SC 29607; or phone: 1-855-581-0937 or website: www.srandi.com

For explanation purposes:

  • a "consumer report" is a written, oral or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in making an employment-related decision about you. Such information may include, for example, credit information, criminal history reports, or driving records; and

  • an "investigative consumer report" is a consumer report in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your prior employers, neighbors, friends, or associates, or with others who may have knowledge concerning any such items of information. In the event an investigative consumer report is requested about you, you are entitled to additional disclosures regarding the nature and scope of the investigation requested, as well as a written summary of your rights under the Fair Credit Reporting Act (“FCRA”).

Under the FCRA, before the Company can obtain a consumer report or investigative consumer report about you for employment purposes, we must have your written authorization. Before we take adverse action on the basis, in whole or in part, of information in that report, you will be provided a copy of that report, the name, address, and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA.

[End of Background Check Disclosures.]

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* This information will only be used to complete the background check process and help avoid misidentification.
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The following information will only be used to complete the authorized records checks.
SR&I will not use it for any other purposes.

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Current and Former Addresses:

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We must verify the education related to the position you are being offered:

School Information (if not applicable, please enter N/A in the Name of School field) *

  

   

  

 


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* Please list the major/field of study on your diploma or degree.
(i.e. Registered Nurse, Medical Assistant, Certified Nursing Assistant, Radiology, Engineering, Accounting, etc)
Enter N/A if you did not graduate or attend school.
 


Please list only Licensure/Certification Registry related to the position you are being offered:


Licensure Information #1 (if not applicable, please enter N/A in the Type/Name field)
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Leave Expire date blank if never expires
 




Licensure Information #2 (if not applicable, please enter N/A in the Type/Name field)
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Leave Expire date blank if never expires
 


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Please list only employment history related to the position you are being offered:


Employment History #1 (if not applicable, please enter N/A in the employer field)
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Employment History #2 (if not applicable, please enter N/A in the employer field)
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Employment History #3 (if not applicable, please enter N/A in the employer field)
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Personal/Professional Reference #1 (if not applicable, please enter N/A.)
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Personal/Professional Reference #2 (if not applicable, please enter N/A.)
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Personal/Professional Reference #3 (if not applicable, please enter N/A.)
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State Notices for Applicant

 Minnesota and Oklahoma Applicants Only: Please check the box to the left if you would like a free copy of any REPORT obtained by the company.

 Massachusetts and New Jersey Applicants: By check the box to the left, you are acknowledging that you have been informed of your right to request a copy of the investigative consumer report we obtained on you and you are exercising your right to obtain a copy of that report.

California Applicants Only: Under California Civil Code section 1786.22, you are entitled to find out what is in the CRA’S file on you with proper identification, as follows:

  • In person, by visual inspection of your file during normal business hours on a reasonable notice. You also may request a copy of the information in person. The CRA may not charge you more than the actual copying costs for providing you with a copy of your file.
  • A summary of all information contained in the CRA file on you that is required to be provided by California Civil Code will be provided to you via telephone, if you have made a written request, with proper identification, for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to you.
  • By requesting a copy be sent to a specified addressee by certified mail. CRAs complying with request for certified mailings shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the CRAs.

"Proper Identification" includes documents such as a valid driver’s license, social security number, military identification card, and credit cards. Only if you cannot identify yourself with such information may the CRA require additional information concerning your employment and personal or family history in order to verify your identify. The CRA will provided trained personnel to explain any information furnished to you and will provide a written explanation of any coded information contained in files maintained on you. This written explanation will be provided whenever a file is provided to you for visual inspection. You may be accompanied by one other person of your choosing, who must furnish reasonable identification. A CRA may require you to furnish a written statement granting permission to the CRA to discuss your file in such person’s presence.

 Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California Law.

 Washington State Applicants only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

 Oregon Applicants only: Information describing your rights under federal and Oregon law regarding consumer identify theft protection, the storage and disposal of your credit information, and remedies available should you suspect or find that Employer has not maintained secured records is available to you upon request.

 Vermont Applicants only: Under Vermont law, no one may access a Vermont consumer's credit report without obtaining the consumer's permission except under the following limited circumstances:
(A) in response to the order of a court having jurisdiction to issue such an order;
(B) for direct mail offers of credit (prescreening), as permitted by the FCRA;
(C) for the purpose of reviewing an account, increasing the credit line on the account, taking collection action on the account, or for other legitimate purposes associated with the account, if the consumer has given ongoing permission to obtain reports in connection with an existing credit relationship;
(D) where the request for a credit report is related to an education loan made, guaranteed, or serviced by the Vermont Student Assistance Corporation;
(E) where the request for a credit report is by the Office of Child Support Services when investigating a child support case;
(F) where the request for a credit report is related to a credit transaction entered into prior to January 1, 1993; or
(G) where the request for a credit report is by the Vermont State Tax Department and is used for the purpose of collecting or investigating delinquent taxes.

If you have obtained consent from the consumer to receive their credit report, the report may only be used for the purpose consented to by the consumer.


 New York Applicants only: By signing the authorization, you acknowledge that you have received a copy of New York Correction Law Article 23-A. You have the right, upon written request, to be informed whether an investigative consumer REPORT was requested. If such a REPORT was requested, you will be provided with the name and address of the consumer reporting agency that prepared the REPORT and you can contact that agency to inspect or receive a copy of the REPORT.

NEW YORK CORRECTION LAW
ARTICLE 23-A
LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY
CONVICTED OF ONE OR MORE CRIMINAL OFFENSES

§750. Definitions.
For the purposes of this article, the following terms shall have the following meanings:
(1) "Public agency" means the state or any local subdivision thereof, or any state or local department, agency, board or commission.

(2) "Private employer" means any person, company, corporation, labor organization or association which employs ten or more persons.

(3) "Direct relationship" means that the nature of criminal conduct for which the person was convicted has a direct bearing on his fitness or ability to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in question.

(4) "License" means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions or instrumentalities as a condition for the lawful practice of any occupation, employment, trade, vocation, business, or profession. Provided, however, that "license" shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire any explosive, pistol, handgun, rifle, shotgun, or other firearm.

(5) "Employment" means any occupation, vocation or employment, or any form of vocational or educational training. Provided, however, that "employment" shall not, for the purposes of this article, include membership in any law enforcement agency.

§751. Applicability.
The provisions of this article shall apply to any application by any person for a license or employment at any public or private employer, who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any license or employment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdiction preceded such employment or granting of a license, except where a mandatory forfeiture, disability or bar to employment is imposed by law, and has not been removed by an executive pardon, certificate of relief from disabilities or certificate of good conduct. Nothing in this article shall be construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with an application for employment made by a prospective employee or previously made by a current employee.

§752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited.
No application for any license or employment, and no employment or license held by an individual, to which the provisions of this article are applicable, shall be denied or acted upon adversely by reason of the individual's having been previously convicted of one or more criminal offenses, or by reason of a finding of lack of "good moral character" when such finding is based upon the fact that the individual has previously been convicted of one or more criminal offenses, unless: (1) There is a direct relationship between one or more of the previous criminal offenses and the specific license or employment sought or held by the individual; or (2) The issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk to property or to the safety or welfare of specific individuals or the general public.

§753. Factors to be considered concerning a previous criminal conviction; presumption.
1. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall consider the following factors:

(a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons previously convicted of one or more criminal offenses.

(b) The specific duties and responsibilities necessarily related to the license or employment sought or held by the person.

(c) The bearing, if any, the criminal offense or offenses for which the person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities.

(d) The time which has elapsed since the occurrence of the criminal offense or offenses.

(e) The age of the person at the time of occurrence of the criminal offense or offenses.

(f) The seriousness of the offense or offenses.

(g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct.

(h) The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of specific individuals or the general public.

2. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein.

§754. Written statement upon denial of license or employment.
At the request of any person previously convicted of one or more criminal offenses who has been denied a license or employment, a public agency or private employer shall provide, within thirty days of a request, a written statement setting forth the reasons for such denial.

§755. Enforcement.
1. In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to article seventy-eight of the civil practice law and rules.

2. In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights pursuant to the powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city commission on human rights.

ACKNOWLEDGMENT AND AUTHORIZATION RELEASE FOR CONSUMER REPORT/BACKGROUND CHECK

By typing in my full name and today's date in the fields below, I acknowledge receipt of the separate document

(Check each box below that applies:)
 and 
  (VIEW)
      which are both available at https://www.srandi.com/downloads.aspx and
 

I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize (a) Surveillance, Resources, & Investigations "SR&I" to request information about you from any public or private information source; (b) anyone to provide information about you to SR&I; (c) SR&I to provide us (employer) one or more reports based on that information; and (d) us to share those reports with others for legitimate business purposes related to your employment. SR&I may conduct a background check investigating your education, work history, professional licenses and credentials, references, address history, social security number validity, right to work, criminal record information, lawsuits, driving record, credit history, and any other information with public or private information sources. I authorize that photocopies of this authorization is as valid as the original. Authorization to be valid for as long as you are an applicant or employee with us.


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