Authorization for Release of Information

IN CONNECTION WITH, AND FOR THE DURATION OF MY EMPLOYMENT WITH EMPLOYER, BROAD CREEK PUBLIC SERVICE DISTRICT, I UNDERSTAND THAT INVESTIGATIVE BACKGROUND INQUIRES ARE TO BE MADE ON MYSELF THAT MAY INCLUDE CONSUMER, CRIMINAL RECORDS, DRIVING RECORDS, CREDIT REPORTS, SOCIAL MEDIA SEARCHES, EMPLOYMENT VERIFICATIONS, EDUCATION VERIFICATIONS, AND OTHER REPORTS. THESE REPORTS WILL INCLUDE INFORMATION AS TO MY CHARACTER, WORK HABITS, PERFORMANCE, AND EXPERIENCE. THE SCOPE OF THIS AUTHORIZATION ALLOWS THE EMPLOYER TO OBTAIN CONSUMER REPORTS AND INVESTIGATIVE CONSUMER REPORTS NOW AND THROUGHOUT THE COURSE OF MY EMPLOYMENT, INCLUDING CONTRACT FOR SERVICES, TO THE EXTENT PERMITTED BY LAW, UNLESS I REVOKE MY CONSENT BY PROVIDING WRITTEN NOTIFICATION TO EMPLOYER.

FURTHER, I UNDERSTAND THAT EMPLOYER MAY BE REQUESTING INFORMATION FROM VARIOUS FEDERAL, STATE AND OTHER AGENCIES WHICH MAINTAIN RECORDS CONCERNING MY PAST EDUCATION, EMPLOYMENT (including WORKER’S COMPENSATION CLAIMS), DRIVING, CRIMINAL, CREDIT, SOCIAL MEDIA, AND CIVIL HISTORIES AND OTHER EXPERIENCES. I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THIS EMPLOYER OR ITS AGENT, INFO QUEST, INC. TO FURNISH THE ABOVE INFORMATION.

Name*

First NameLast Name

Previous Last Names*

Social Security Number*

Date of Birth*

DOB is requested to assure accurate retrieval of records.

Drivers License Number*

State of Issue *

Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I authorize the company to contact my current employer for verification of employment:*

YesNo

I authorize the company to contact all reference checks provided:*

YesNo

(If no to either, please explain)

Please check if applies

CA, MN, OK, and NY applicants only: please check here to have a copy of your consumer report sent directly to you by Info Quest, Inc.

To ensure accurate record retrieval, if you have:

Lived in India? Please provide father’s full name.

First NameLast Name

Lived in Puerto Rico? Please provide mother’s maiden name.

First NameLast Name

Lived in Canada? Please notify HR for additional forms.

I understand by signing my name below that I am signing the Authorization form directing the background check, as described above, and I certify that I have read the Disclosure information above. If an investigative consumer report, I have received the FCRA Summary of Your Rights, and if a California resident/applicant, the A Summary of Your Rights Under the Provisions of California Civil Code 1786.22. If a New York applicant/employee, I acknowledge receipt of Article 23-A of the New York Correction Law.

Applicant's Signature*

By signing my name above I understand and agree to each and all of the Terms and Conditions in this form. My electronic signature is legally binding.

Date*

Date

Email Address*

example@example.com

The consumer and/or investigative consumer report(s) will be obtained from:
Info Quest Inc., PO Box 15521, Surfside Beach, SC 29587. Info Quest’s information and privacy policy can be found at www.infoquesthr.com

Authorization for Release of Information

Fair Credit Reporting Act Disclosure Statement