Fillable Printable Background Check Disclosure and Authorization Form
Fillable Printable Background Check Disclosure and Authorization Form
Background Check Disclosure and Authorization Form
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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” (a background 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 backgr ound reports on you for empl oyment 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 b e reached at 800-367-5 93 3.
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; and drug testing results. 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.) 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 outsid e organization.
You may reque s t 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 F air Credit Reporting Act is also being provided to you with this form.
STATE SPECIFIC NOTICES
If you live or work for the Company i n the states listed below, pl ease note the following:
CALIFORNIA: You may view the file that ADP Screening and Selection Services 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 mail. You may also ask for a file-summary by telephone. ADP Screening and Selection Services can answer questions
about information in your file, including a ny coded informati on. If you come in person, an other 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 ADP Screening and Selection Services. You will get this
information within 5 business days of our rec eipt of your request. You have the right to ask ADP Screening and Selection Services 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 or dere d an
investigative consumer report from ADP Screening and Selection Services. You may inspect and order a free copy of the report by
contacting ADP Screening a nd Selection Services.
MINNESOTA: If you submit a request to us in writing, you have the rig ht to get from the Company a complete and accurate discl osure of
the nature and scope of the co nsumer report or investigative consumer report ordered, if any.
NEW YORK: If you submit a requ est to us in writing, you have the right to kno w whethe r the Company ordered a consumer rep ort 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. 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 th e nat ure and s c ope of the inv estigativ e co ns umer report we ordered, if an y. You also have the r ight to ask ADP Screening
and Selection Services for a written summary of your rights under the Washington Fair Credit Reporting Act. If the Company obtains
information bearin g on your credit worthiness, credit sta nding or credit ca pacity, it will be us ed to evaluate whether you would present an
unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.
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V0611
AUTHORIZATION FOR BACKGROUND CHEC KS
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 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; all other private and public sector
repositories of information; and any other person, organization, or agency with any information about or concerning me.
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 te sting.
I agree the Company may rely on this authorization to order background reports, including investigative consumer reports,
from companies other than ADP Screening and Selection Services 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 my personal information on
this form is true and correct and understand that dishonesty will disqualify me from consideration for employment with the
Company, or if I am hired or already work for the Company, that my employment may be terminated.
Last Name _________ ______________ ___________ First ___ _____________________ Middle ___ _____________ ____
Maiden/Other Names ___ ____________ __________________________ ______ Years Used ________________ _______
Social Security Number __________ _________________________ _______________ __________________________ ___
Driver’s Lice nse Number ____________________ _________________________ ___ State _____________ ____________
FOR IDENTIFICATION PURPOSES ONLY: Date of Birth ____/____/____ (Month/Day/Year)
Addresses Within The Past Seven Years (use a separate sheet as needed)
Present Street Address _________________ __________________________ ______________ ______________________
City/State/ZIP _____________ _______________ ______________ __________________________ _______________ ____
Prior Street Addres s ___________________________________ _________________________ ______________________
From _____/____ ___/______ (Month/Day/Year) To _____/___ ____/______ (Month/Day/Y ear)
City/State/ZIP _____________ _______________ ______________ __________________________ _______________ ____
__________________________ ____________________________________ _____/_______/________
Signature Date: (Month/Day/Year)
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:
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V0611
NEW YORK CORRECTION LAW
ARTICLE 23-A
LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY
CONVICTED OF ONE OR MORE CRIMINAL OFFENSES
Section 750. Definition s.
751. Applicability.
752. Unfair discrimination against persons previously convicted of one or mo re criminal offenses prohi bited.
753. Factors to b e co nsidered concerning a previous criminal conviction; presumption.
754. Written statement upon denial of license or employmen t .
755. Enforcement.
§750. Definitions. F or the purposes of this article, the following terms shall have the fo llowing meanings:
(1) "Public agency" means the state or any local subdivisio n thereof, or an y state or local department, agency, boar d or commission.
(2) "Private employer" mea ns any person, company, corporation, labor organization or association which emplo ys ten or more
persons.
(3) "Direct relationship" means that the nature of criminal conduct for which the person was convicted has a direct bearin g on his
fitness or ability to perform o ne or more of the duties or responsibilities necessaril y 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 condi t ion for the lawful practice of any occupation, empl oyment, trade, vocation, business, or profession.
Provided, however, that "license" shall not, for the purpose s 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. P r ovided,
however, that "employment" shall not, for the purpos es of this article, include membership in any law enforcement agency.
§751. Applicability. The provisions of this article shall apply to an y application by an y person for a license or employment at any public or
private employer, who has previously been convicted of one or more crimi nal offenses in this state or in any other jurisdiction, and to any
license or empl oyment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdictio n preceded
such employment or granting of a license, except where a mandatory forfeiture, disability or bar to emplo yment 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 h ave with respect to an intentional misrepresentati on 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 crimin al o ffenses prohibited. No application for any
license or empl oyment, and no employment or license held by an individual, to which the provisi ons of this article are applicable, shall be
denied or acted upon advers ely by reason of the individual's having been previ ously convicted of one or more criminal offenses, or by reas on
of a finding of lack of "good moral character" when such finding is based upon the fact that the indiv idual has prev ious ly been conv icted 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 continuati on 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 individ uals or the general pub lic.
§753. Factors to be considered con cerning a pre vious 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 follo wing factors:
(a) The public policy of this state, as express ed in this act, to encourage the licensure and employment of persons
previously convicted of one or more criminal offenses. (b) The specific duti es and responsibilities neces s arily related to the
license or employment sought or held b y 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 abili ty to perform one or more such duties or respo nsibilities.
(d) The time which has elapsed since the oc currence of the criminal offense or offenses.
(e) The age of the person at the time of occu rrence 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 beha lf, in regard to his rehabilitation and good conduct.
(h) The legitimate interest of the public agen cy or private employer in protecting prop erty, 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 considerati on to a certificate of relief from disabilit ies or a certificate of good conduct issu ed to the applicant, which
certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein.
§754. Written statement upon d enial o f license o r employment. At the request of any person previo usly convicted of one or more criminal
offenses who has been denied a license or emplo yment, a public agency or private employer sha ll provide, within thirty days of a request, a
written statement setting forth the reasons for such denia l.
§755. Enforcement.
1. In relation to actions by public agenci es, the provisions of this article shall be enforcea ble 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 po wers and proced ures set forth in article fifteen of the executive law, and, concurrently, b y the Ne w York city
commission on human rights.
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