Bacground Check Disclosure 

and Authorization Form Request


BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION FORM


In the interest of maintaining the safety and security of our customers, employees and property, ___________________________ (the “Company”) will order a “consumer report” on you in connection with your employment application, and if you are hired, or if you already work for the Company, may order additional background reports on you for employment purposes.


The background check company, Ceiba Inelligent Solutions (the "Background Check Company"), will prepare the background report for the Company. The Background Check Company is located at 9121 Anson Way, Raleigh, North Carolina 27615, and can be reached by phone at 919-258-2981 or at their Internet Web site address www.ceibagroup.org.


The background report may contain information concerning your character, general reputation, personal characteristics, mode of living, and credit standing. The types of information that may be ordered include but are not limited to: Social Security number verification; criminal, public, educational and, as appropriate, driving records checks; verification of prior employment; reference, licensing and certification checks; credit reports; drug testing results; and, if applicable, worker’s compensation injuries. Workers’ compensation information will only be requested in compliance with federal Americans with Disabilities Act and/or any other applicable federal, state or local laws and only after a conditional job offer is made. Credit history will only be requested when permitted by law and where such information is substantially related to the duties and responsibilities of the position for which you are applying. The information may be obtained from private and public record sources, including personal interviews with your associates, friends, and neighbors. (An “investigative consumer report” is a background report that includes information from such personal interviews, except in California where that term means any background report that is not a credit report.) The nature and scope of the most common form of investigative consumer report is an investigation into your education and/or employment history conducted by the Background Check Company or another outside organization.


You may request more information about the nature and scope of an investigative consumer report, if any, by telephoning the Company at

________________________. A summary of your rights under the Fair Credit Reporting Act is also being provided to you with this form. The Fair Credit Reporting Act gives you specific rights in dealing with consumer reporting agencies. You will find these rights summarized on A Summary of Your Rights Under the Fair Credit Reporting Act and A Summary of Your Rights Under the Provisions of California Civil Code Section 1786.22 for California residents..


STATE LAW NOTICES


If you live or work for the Company in the states listed below, please note the following:


CALIFORNIA: You may view the file that the Background Check Company has for you, and order a copy of the file, upon submitting proper identification and paying copying costs, by coming to their offices, during normal business hours and on reasonable notice, or by certified mail or mail. You may also ask for a file-summary by telephone. The Background Check Company can answer questions about information in your file, including any coded information. If you come in person, another person can come with you, so long as that person can show proper identification.


MAINE: If you ask us, you have the right to know whether the Company ordered an investigative consumer report on you. You may request the name, address, and telephone number of the nearest office for the Background Check Company. You will get this information within 5 business days of our receipt of your request. You have the right to ask the Background Check Company for a free copy of the report.


MARYLAND: If the Company obtains credit history information on you, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.


MASSACHUSETTS/NEW JERSEY: If you submit a request to us in writing, you have the right to know whether the Company ordered an investigative consumer report from the Background Check Company. You may inspect and order a free copy of the report by contacting the Background Check Company.


MINNESOTA: If you submit a request to us in writing, you have the right to get from the Company a complete and accurate disclosure of the nature and scope of the consumer report or investigative consumer report ordered, if any.


NEW YORK: If you submit a request to us in writing, you have the right to know whether the Company ordered a consumer report or an

investigative consumer report from the Background Check Company, and you will be provided with the name and address of the Background Check Company. You may inspect and order a free copy of the reports by contacting the Background Check Company. By signing below, you certify you have received a copy of Article 23A of the New York Correction Law is being provided with this form.


OREGON: If the Company obtains credit history information on you, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.


WASHINGTON STATE: If you submit a request to us in writing, you have the right to get from the Company a complete and accurate  disclosure of the nature and scope of the investigative consumer report we ordered, if any. You also have the right to ask the Background Check Company for a written summary of your rights under the Washington Fair Credit Reporting Act. If the Company obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.


AUTHORIZATION FOR BACKGROUND CHECKS


After carefully reading this Background Check Disclosure and Authorization form, I authorize the Company to order my background report, including investigative consumer reports. I understand that the Company may rely on this authorization to order additional background reports, including investigative consumer reports, during my employment without asking me for my authorization again as allowed by law.


I also authorize the following agencies and entities to disclose to the Background Check Company and its agents all information about or concerning me, including but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; if applicable, worker’s compensation injuries; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. Workers’ compensation information will only be requested in compliance with federal Americans with Disabilities Act and/or any other applicable federal, state or local laws and only after a conditional job offer is made. The information that can be disclosed to the Background Check Company and its agents includes, but is not limited to, information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses and substance abuse testing.


I agree the Company may rely on this authorization to order background reports, including investigative consumer reports, from companies other than the Background Check Company without asking me for my authorization again as allowed by law. I also agree that a copy of this form is valid like the signed original. I certify that all of the personal information I provided is true and correct.


Last Name ________________________________________ 


First ______________________________________________ 


Middle ____________________


Maiden/Other Names _________________________________________________ 


Years Used __________________


If you live or work for the Company in California, Minnesota or Oklahoma: Check this box if you would like a free copy of your background check report: ☐


__________________________________________________ 

Signature


_____/_______/________

Date: (Month/Day/


BACKGROUND CHECK INFORMATION:


The information requested below is collected solely for the purpose of aiding the Company in running a background check in connection with your application for employment. The employer is requesting that you provide this information to assist in conducting a thorough background check.


For residents of, or for jobs located in Utah, please do NOT provide your date of birth, social security number or driver’s license number until instructed to do so by the Company.


First Name _______________________

Middle Name __________________

Last Name_________________________

Date of Birth ____/____/____ 

(Month/Day/Year)

Social Security Number ____________________________________________________

Driver’s License Number ______________________________ 

State Issuing License_________________________

Enter Any Other Names Used (including maiden names):

First Name _________________________Middle Name __________________Last Name_________________________

First Name _________________________Middle Name __________________Last Name_________________________

First Name _________________________Middle Name __________________Last

Name_________________________

Addresses Within The Past Seven Years (use a separate sheet as needed)

Present Street Address ___________________________________________________________

City/State/ZIP ___________________________________________________________________________

Prior Street Address _________________________________________________________________

From _____/_______/______ (Month/Day/Year) To _____/_______/______ (Month/Day/Year)

City/State/ZIP __________________________________________________________________________

Prior Street Address _________________________________________________________________

From _____/_______/______ (Month/Day/Year) To _____/_______/______ (Month/Day/Year)

City/State/ZIP __________________________________________________________________________


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