Fillable Printable Consumer Disclosure And Authorization Form - Michigan State University

Consumer Disclosure And Authorization Form - Michigan State University

Michigan State University

CONSUMER DISCLOSURE AND AUTHORIZATION FORM

FOR FACULTY, ACADEMIC STAFF AND EXECUTIVE MANAGEMENT

Disclosure Regarding Background Investigation

Michigan State University (the “Company”) may request, for lawful employment purposes, background information

about you from a consumer reporting agency in connection with your employment or application for employment

(including independent contractor assignments, as applicable). This background information may be obtained in the

form of consumer reports and/or investigative consumer reports (commonly known as “background reports”). These

background reports may be obtained at any time after receipt of your authorization and, if you are hired or engaged by

the Company, throughout your employment or your contract period. The information obtained from the background

reports will only be used by the Company for employment purposes as provided under the Fair Credit Reporting Act,

which means that the information obtained from the background reports will be used for the purpose of evaluating a

consumer for employment, promotion, reassignment or retention of the employee.

HireRight, Inc., or another consumer reporting agency, will prepare or assemble the background reports for the

Company. HireRight, Inc. is located and can be contacted by mail at 5151 California, Irvine, CA 92617, and HireRight

can be contacted by phone at (800) 400-2761. Information about HireRight’s privacy practices is available at

www.hireright.com/Privacy-Policy.aspx.

The background reports will include information from the following background checks:

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Verification of Social Security Number

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Examination of County Criminal Records

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Examination of State Criminal Records

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Examination of Federal Criminal Records

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Examination of Sex Offender Registries

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Examination of Federal Debarment Lists

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Verification of Degrees

A more comprehensive background investigation may be required pursuant to state or federal law or for certain

sensitive positions (such as those with significant financial responsibilities).

This information may be obtained from private and public record sources, including, as appropriate: government

agencies and courthouses and educational institutions.

You may request more information about the nature and scope of any investigative consumer reports by contacting the

Company. A summary of your rights under the Fair Credit Reporting Act is also being provided to you.

ADDITIONAL STATE LAW NOTICES

If you are a California, Maine, Massachusetts, New York or Washington State applicant, employee or contractor, please

also note:

CALIFORNIA: Pursuant to section 1786.22 of the California Civil Code, you may view the file maintained on you by

HireRight during normal business hours. You may also obtain a copy of this file, upon submitting proper identification

and paying the costs of duplication services, by appearing at HireRight’s offices in person, during normal business hours

and on reasonable notice, or by certified mail. You may also receive a summary of the file by telephone, upon

submitting proper identification and written request. HireRight has trained personnel available to explain your file to

you, including any coded information, and will provide a written explanation of any coded information contained in your

file. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper

identification. “Proper identification” includes documents such as a valid driver’s license, social security account

number, military identification card, and credit cards. If you cannot identify yourself with such information, HireRight

may require additional information concerning your employment and personal or family history to verify your identity.

MAINE: You have the right, upon request, to be informed of whether an investigative consumer report was requested,

and if one was requested, the name and address of the consumer reporting agency furnishing the report. You may

request and receive from the Company, within five business days of our receipt of your request, the name, address and

telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an

investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly

receive from all such agencies copies of any such reports.

MASSACHUSETTS: If we request an investigative consumer report, you have the right, upon written request, to a copy

of the report.

NEW YORK: You have the right, upon written request, to be informed of whether or not an investigative consumer

report was requested. If an investigative consumer report is requested, you will be provided with the name and

address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of the report by

contacting that agency. Attached below is additional information about New York law.

WASHINGTON STATE: If the Company requests an investigative consumer report, you have the right, upon written

request made within a reasonable period of time after your receipt of this disclosure, to receive from the Company a

complete and accurate disclosure of the nature and scope of the investigation requested by the Company. 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.

Authorization of Background Investigation

I have carefully read and understand this Disclosure and Authorization form and the attached summary of rights under

the Fair Credit Reporting Act. By my signature below, I consent to preparation of background reports by a consumer

reporting agency such as HireRight, Inc., and to the release of such background reports to the Company and its

designated representatives and agents, for the purpose of assisting the Company in making a determination as to my

eligibility for employment (including independent contractor assignments, as applicable), promotion, retention or for

other lawful employment purposes. I understand that if the Company hires me or contracts for my services, my

consent will apply, and the Company may obtain background reports, throughout my employment or contract period.

I understand that information contained in my employment or contractor application, or otherwise disclosed by me

before or during my employment or contract assignment, if any, may be used for the purpose of obtaining and

evaluating background reports on me. I also understand that nothing herein shall be construed as an offer of

employment or contract for services.

I hereby authorize law enforcement agencies, learning institutions (including public and private schools and universities),

information service bureaus, credit bureaus, record/data repositories, and courts (federal, state and local) to furnish any

and all information on me that is requested by the consumer reporting agency.

By my signature below, I also certify the information I provided on and in connection with this form is true, accurate and

complete. I agree that this form in original, faxed, photocopied or electronic (including electronically signed) form, will

be valid for any background reports that may be requested by or on behalf of the Company.

□ California, Minnesota or Oklahoma applicants only: Please check this box if you would like to receive (whenever

you have such right under the applicable state law) a copy of your background report if one is obtained on you by the

Company.

Applicant Last Name _______________________ First _________________ Middle _____________

Applicant Signature ________________________________ Date

NEW YORK CORRECTION LAW

ARTICLE 23-A

LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY CONVICTED OF ONE OR MORE CRIMINAL OFFENSES

Section 750. Definitions.

751. Applicability.

752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited.

753. Factors to be considered concerning a previous criminal conviction; presumption.

754. Written statement upon denial of license or employment.

755. Enforcement.

§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.

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.

Para informacion en español, visite

Pennsylvania Ave., N.W., Washington, DC 20580

A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of

consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and

specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental

history records). Here is a summary of your major rights under the FCRA. For more information, including

information about additional rights, go to

www.ftcgov/credit or write to:

Consumer Response Center, Room 130-A,

Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, DC 20580.

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You must be told if information in your file has been used against you. Anyone who uses a credit report or

another type of consumer report to deny your application for credit, insurance, or employment – or to take

another adverse action against you – must tell you, and must give you the name, address, and phone number of

the agency that provided the information.

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You have the right to know what is in your file. You may request and obtain all the information about you in

the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper

identification, which may include your Social Security number. In many cases, the disclosure will be free. You

are entitled to a free file disclosure if:

a person has taken adverse action against you because of information in your credit report;

you are the victim of identity theft and place a fraud alert in your file;

your file contains inaccurate information as a result of fraud;

you are on public assistance;

you are unemployed but expect to apply for employment within 60 days.

In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon

request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See

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You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness

based on information from credit bureaus. You may request a credit score from consumer reporting agencies

that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In

some mortgage transactions, you will receive credit score information for free from the mortgage lender.

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You have the right to dispute incomplete or inaccurate information. If you identify information in your file that

is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless

your dispute is frivolous. See

http://www.ftc.gov/credit for an explanation of dispute procedures.

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Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information.

Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days.

However, a consumer agency may continue to report information it has verified as accurate.

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Consumer reporting agencies may not report outdated negative information. In most cases, a consumer

reporting agency may not report negative information that is more than seven years old, or bankruptcies that

are more than 10 years old.

www.ftc.gov/credit o escribe a la FTC Consumer Response Center, Room 130-A 600

http://www.ftc.gov/credit for additional information.

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Access to your file is limited. A consumer reporting agency may provide information about you only to people

with a valid need – usually to consider an application with a creditor, insurer, employer, landlord, or other

business. The FCRA specifies those with a valid need for access.

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You must give your consent for reports to be provided to employers. A consumer reporting agency may not

give out information about you to your employer, or a potential employer, without your written consent given

to the employer. Written consent generally is not required in the trucking industry. For more information, go

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You may limit “prescreened” offers of credit and insurance you get based on information in your credit report.

Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if

you choose to remove your name and address from the lists these offers are based on. You may opt-out with

the nationwide credit bureaus at 1-888-567-8688.

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You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer

reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue

in state or federal court.

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Identity theft victims and active duty military personnel have additional rights.

For more information, visit

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may

have more rights under state law. For more information, contact your state or local consumer protection agency or

your state Attorney General. Federal enforcers are:

TYPE OF BUSINESS: PLEASE CONTACT:

Consumer reporting agencies, creditors and others not listed

below

Federal Trade Commission: Consumer Response Center –

FCRA Washington, DC 20580 1-877-382-4357

National banks, federal branches/agencies of foreign banks

(word “National” or initials “N.A.” appear in or after bank’s

name)

Office of the Comptroller of the Currency Compliance

Management, Mail Stop 6-6 Washington, DC 20219

800-613-6743

Federal Reserve System member banks (except national

banks, and federal branches/agencies of foreign banks)

Federal Reserve Board Division of Consumer & Community

Affairs Washington, DC 20551 202-452-3693

Savings associations and federally chartered savings banks

(word “Federal” or initials “F.S.B.” appear in federal

institution’s name)

Office of Thrift Supervision Consumer Complaints Washington,

DC 20552 800-842-6929

Federal credit unions (words “Federal Credit Union” appear in

institution’s name)

National Credit Union Administration 1775 Duke Street

Alexandria, VA 22314 703-519-4600

State-chartered banks that are not members of the Federal

Reserve System

Federal Deposit Insurance Corporation Consumer Response

Center 2345 Grand Avenue, Suite 100 Kansas City, MO

64108-2638 1-877-275-3342

Air, surface, or rail common carriers regulated by former Civil

Aeronautics Board or Interstate Commerce Commission

Department of Transportation, Office of Financial Management

Washington, DC 20590 202-366-1306

Activities subject to the Packers and Stockyards Act, 1921

Department of Agriculture Office of Deputy Administrator-

GIPSA Washington, DC 20250 202-720-7051

http://www.ftc.gov/credit.