Background Check Disclosure And Authorization Form printable pdf download

BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION FORM

In the interest of maintaining the safety and security of our customers, employees and property, Holistic HomeCare

Associates (the “Company”) will order a “consumer report” (a background report) or “investigative 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, ADP Screening and Selection Services, will prepare the background report for the

Company. ADP Screening and Selection Services is located at 301 Remington Street, Fort Collins, CO, 80524, and can

be reached by phone at 800-367-5933 or at their Internet Web site address

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; if applicable, workers’

compensation injuries. The Company may order a background report under your legal name and any other names you

may have used. 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 ADP Screening and

Selection Services 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 646-240-4888. 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 as provided here. Request the name, address, and

telephone number of the nearest office for ADP Screening and Selection Services. You will get this information within 5

business days of our receipt of your request. You have the right to ask ADP Screening and Selection Services for a free

copy of the report.

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 ADP Screening and Selection Services, and you will be

provided with the name and address of ADP

Screening and Selection Services. You may inspect and order a free copy of the reports by contacting ADP Screening

and Selection Services. 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.

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, under my legal name, including any former names I may

have used. 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 ADP Screening and Selection Services 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 ADP Screening and Selection Services 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.

Background Check Disclosure And Authorization Form

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