Community Service Volunteer Application (Page 4 of 4) in pdf

NOTICE – BACKGROUND AUTHORIZATION FORM

In connection with your application and/or employment with (Goodwill Industries Akron) (Employer) this notice is provided to

inform you that a “consumer report” and/or “investigative consumer report”, as defined by the Fair Credit Reporting Act, may be

obtained from a consumer reporting agency for employment purposes. These types of reports may include information as to your

character, general reputation, personal characteristics and mode of living, whichever are applicable. The report may also contain

information about you relating to criminal history, credit history, driving and/or motor vehicle records, social security verification,

verification of your education or employment history and other background checks. They may involve interviews with sources such

as your neighbors, friends or associates. You have the right, upon written request made within a reasonable amount time after the

receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report to , 17295

Foltz Industrial Parkway, Suite B, Strongsville, OH 44149 [1-877-992-4325]. For information about Crimcheck.com’s privacy

practices, see The scope of this notice and authorization is not limited to the present and, if hired, will continue

and allow Employer to conduct future screenings for retention, promotion or reassignment, unless revoked by you in writing.

Employer also reserves the right to share such reports with a third-party for whom you will be placed to work as a representative of

Employer, if applicable.

Acknowledgement and Authorization

You hereby authorize, without reservation, the obtaining of a “consumer report” and/or “investigative consumer report” at any time

after receipt of this authorization and during the course of your employment, to the extent permitted by law. You also confirm your

understanding and provide consent for this report to be shared with a third-party for whom you may be placed to work as a

representative of Employer, if applicable.

Minnesota & Oklahoma applicants or employees only: Under state law you have a right to receive a copy of your consumer

report, free of charge, if one is requested by Employer. By checking “yes”, a copy will be provided to you at the address you provide

on this notice.

I would like to receive a copy of my consumer report: (

) Yes

(

) No

New York applicants or employees only: Under state law you have the right to inspect and receive a copy of any investigative

consumer report requested by Employer by contacting directly. You also acknowledge receipt of a copy of Article

23-A of the New York Correction Law by signing this notice.

Washington State applicants or employees only: Under state law you have a right to request a copy of the Washington Fair Credit

Reporting Act’s disclosures to consumers (RCW 19.182.070) by contacting directly.

California, Maine applicants or employees only: Under state law you have a right to receive a copy of your investigative consumer

report and/or consumer credit report, free of charge, if one is requested by Employer. By checking “yes” a copy will be provided to

you at the address you provide on this Notice.

I would like to receive a copy of my consumer report: (

) Yes

(

) No

Signature: ____________________________________________ Date: ______________________________

Name:

________________________ SSN_____________- __________________- _______________

**Previous Names Used: (Within the past 7 years)_____________________________________________________________

Current Home Address:____________________________________________________________________________________

County

Street Address (No P.O. Boxes)

City

State

Zip Code

How long have you lived at current address? ___________

**Date of Birth: _____ / _____ /___________ Driver’s License Number: _______________________ State: _________

Have you ever been convicted of a crime other than minor traffic offenses?

Y_______ N_______

If yes, provide explanation:

Year of Offense:

County offense was committed: ________________Offense Description: _________________________

_______________________________________________________________________________________________________

City offense was committed: _______________________

** will only use this information for background screening purposes and no other purpose.

Community Service Volunteer Application Page 4

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