SecurTest Consumer Authorization for FBI and International Self-Pay

You are now on the webpage for the SecurTest, Inc. online background screening authorization form. In order to initiate a background check with SecurTest, Inc., you must complete these authorizations and certify that you meet the qualifications to receive the background reports. * are required fields. To obtain your background check, you are required to pay securely online using a Visa, Mastercard or Discover. We do not accept American Express.
Click the box*

I Understand and Agree that all federal, state, local, or other notices and authorizations viewed will be an attachment to my email confirmation.

Consumer Authorization Form
This authorization is required for us to complete your background check. The information you provide in this form is confidential and secure.

By completing the authorization online, you hereby certify that your electronic signature may be used as if it were your original handwritten signature by SecurTest, Inc., iReviewNow, LLC, and/or court researchers, investigators, or government entities to verify your authorization for your background check.

You may complete this authorization online by pressing "Next." The authorization will not be complete until you click the "Submit" button on the final page. You must complete this authorization in one sitting. Your information is SSL-protected and secure.

IMPORTANT DISCLAIMER: SecurTest, Inc. can oversee both your FBI background check as well as the additional recommended background checks. In order to initiate an FBI and the additional background checks conducted by SecurTest, Inc., you will need to complete authorization documentation provided by SecurTest.

Background Check Participation

As part of your application, SecurTest, Inc. will conduct your background check.

Please read the following Consumer Authorization form in its entirety. The language in the disclosure statements is required under the Fair Credit Reporting Act. SecurTest’s background investigation is restricted to verification of your identity, verification of your Social Security Number (if applicable), and a comprehensive criminal history search.

An important feature of the SecurTest background check includes iReviewNow®, a patented solution that allows you to view your report at the same time we do. Thus, please provide your email and cell phone number so that SecurTest can send you your report or information on how to securely view it online. You are an important part of the background screening process. Reviewing your report will ensure that you have authenticated its accuracy, identified any inaccuracies, file any disputes, explain any information, and provide any self-improvement steps you wish us to consider. iReviewNow, LLC is not a consumer reporting agency, but the exclusive system that allows you to instantly view and comment on your background report.

The information you provide is secured and is neither sold nor redistributed by SecurTest or iReviewNow, LLC. Be sure to carefully complete each form. You may contact SecurTest at (800) 445-8001 or compliance@securtest.com if you have any questions.

Thank you for your participation and cooperation in this important step.

You must answer each question and press "Next."

The website and form are confidential and secure. You can be confident that your personal identifiers are protected.

CONSUMER AUTHORIZATON

I. I understand that an investigative report will be prepared and reported by SecurTest concerning my background, including any criminal history information, authentication of my identity, validity of any social security number issued by the Social Security Administration, and other background information. The Summary of Rights under the FCRA details additional information as defined by the FCRA. This background check is limited to an investigation of criminal records, validation of your identity and residence history, Motor Vehicle Records Search, and Employment Verification.

I understand that SecurTest, Inc. and or its background screening agents or investigators, or authorized parties, may be requesting information from public and private sources about any of the information noted earlier in this paragraph in connection with the company or organization requesting this investigative report. We do not check your credit report without an additional notice and authorization.

II. IF APPLICABLE, Medical and worker’s compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit Reporting Act (FCRA, Public Law 91-508, Title VI), I am entitled to know if the considerations for which I am applying are denied because of information obtained from a consumer reporting agency. If so, I will be notified and be given the name of the agency providing that report. This section II does not apply to you, though we must communicate this information to you.

III. I acknowledge that a telephonic, electronic, online, facsimile (FAX) or photographic copy of this release shall be as valid as the original. This release is valid for most federal, state and county agencies. I have received a copy of my Fair Credit Reporting Act (FCRA) rights found on page 7.

IV. I hereby authorize, without reservation, any financial institution, law enforcement agency, clerk of court, government agencies that store records, information service bureau, school, employer or insurance company contacted by SecurTest, Inc., or their background screening agents, investigators, or entities to furnish the information described in Section I.

V. As the subject of an international background check, we must rely on court researchers located in the various countries that allow a background investigation. SecurTest cannot be either an insurer or a guarantor of the accuracy of the information received from international police, courts or other sources, and as such, rely on you to complete iReviewNow to ensure the accuracy of your report. Therefore, I release and forever hold harmless SecurTest, their Affiliates, Assigns, their officers, agents, and employees from liability for any negligence of third party furnishers of my criminal history file obtained outside the United States of America.

INVESTIGATIVE CONSUMER AGENCY CONDUCTING INVESTIGATION, unless noted herein:

SecurTest, Inc. - 600 Grand Panama Blvd. - Suite 202 - Panama City Beach, FL 32407 (800) 445-8001 - www.securtest.com
Sign with your mouse like your signature*

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Date*

MonthDayYear
Date

VI. I understand that if I am a resident of California, Minnesota, Oklahoma, Connecticut, or New York, I may obtain a copy of the background report.*

I understand.
Please note, regardless of your state of residency, you will have automatic access to your report through iReviewNow.
Who must be fingerprinted? The purpose of the fingerprints is to conduct a US based background check. So, who should be fingerprinted?

1. US Citizens must submit fingerprints.
2. Non-US Citizens that have lived in the US in the past 10 years (past your 18th birthday).

Who does not need to be fingerprinted?

NON-US CITIZENS that have not lived in the U.S. will not be required to submit fingerprints.

Finding a fingerprinting location in the USA. Generally, your local Sheriff's Office provides fingerprinting services.

Finding a fingerprinting location outside the USA. You will need to take the fingerprint card and FBI information form to be fingerprinted. Your prints must be rolled in ink on the FBI card and meet the legibility standards of the FBI. Contact the local US Embassy or Consulate to determine if they can fingerprint you. You may need to contact local law enforcement agencies as well. Mail by Certified Mail or send by Overnight Express for faster processing of the FINGERPRINT CARD and FBI INFORMATION FORM in a large thick envelope that protects the card from being folded or bent to the address we will provide to you in our email. We recommend that you use a certified carrier, such as FedEx. United Parcel Service (UPS) and DHL Express. Additional instructions will be emailed to you.

Are you a resident of a member state to the European Union?*

YesNo
Notice to those candidates located within the European Union
I understand the preceding notices and consent to transfer my personal information to SecurTest, Inc. as required for the completion of my background check.
While we remain dedicated to protecting your privacy and any personal information we obtain, SecurTest, Inc., being located entirely within the United States of America, is not covered by privacy laws established by the European Commission.
- I, the individual requesting this background check, acknowledge that SecurTest, Inc. will, in the course of conducting the background check at my request, need to further transfer certain portions of my personal information to third parties not covered by a decision adopted by the European Commission pursuant to Article 25(6) of Directive 95/46/EC. I further acknowledge that after this onward transfer, the data may be processed by a controller established in a country where there is not an adequate level of protection of the privacy of individuals as established by directive of the European Commission. Third parties which may receive my personal information include consumer reporting agencies, private background data information providers, and government agencies located within the United States of America. Following the completion of my background report and my explicit consent, SecurTest or its assigns will release my background report, including certain personal information, to the individual school I indicate, if any. I am responsible for knowing the country in which this school is located and any applicable privacy laws.
Signature - Use Your Mouse to Sign in the Box*

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Today's Date

MonthDayYear

Please Carefully Complete the Following
As part of the background investigation, we verify the information you provide as being accurate.

The website and form are confidential and secure. You can be confident that your personal identifiers are protected.
Your Legal First Name*
Your Legal Middle Name (if any)
Your Legal Last Name*
Suffix Name (if any, such as Sr, Jr, II, III, etc.)
Your Maiden Name (if any)
Have you ever used any other Name(s), such as married names, etc.?

YesNo
Please list any other Name(s) Used. If you have used multiple names, please separate each name by pressing Enter.
To obtain your background check, you are required to pay securely online using a Visa, Mastercard or Discover. We do not accept American Express.*

I understand and agree*.

Below are 4 background screening options.

Package 1. USA-Based FBI Criminal Background Screening ONLY

ONLY AVAILABLE TO US CITIZENS AND LAWFUL PERMANENT RESIDENTS

This package is for candidates that have ONLY resided in the USA within the past 10 years or require an FBI Rap Sheet (Background Report). An additional fee of $89.00 will be added if the FBI Report requires an Apostille with the US Department of State. These fees do not include express shipping or mailing.

Package 1A. USA-Based FBI Criminal Background Screening plus Apostille.

Package 2. USA-Based FBI Criminal Background Screening AND International Screening

ONLY AVAILABLE TO US CITIZENS AND LAWFUL PERMANENT RESIDENTS

This package is for candidates that have lived in the USA and at least one foreign country within the past 10 years with the following requirements.

Minimum age of 18 years or older while residing in the foreign country

Residency was not because of a college intership or study-abroad program

Package 3. International Screening ONLY

This package is for non-U.S. citizens that have never lived in the USA and have only resided outside the USA (foreign country.)

Package 4. International Screening AND US-Based Commercial Screening for International Candidates

This package is intended for non-US citizens who have lived in the USA AND in other countries, but did not have a Green Card (right-to-work visa.)
Background Screening Packages (All prices in USD) Click on the option that describes you.*

1.) – USA-Based FBI Criminal Background Screening – only available for US Citizens and lawful permanent residents that have never lived outside the U.S. ($129.00)1a) - FBI Fingerprint Background Report plus Apostille ($218.00)2.) – USA-Based FBI Criminal Background Screening And International Screening – only available for US Citizens and lawful permanent residents that have also lived in a non-U.S. Country longer than 6 months and 18 years of age or older ($129.00 + Country fees below)3.) - International Background Checks only (if you have never lived in the USA ($79.99 + Country fees below)4.) – SecurTest U.S. Background for those that are NOT US citizens or lawful permanent residents that have ONLY lived in the USA. Does not include an FBI check ($235.00).

Some countries may require an Apostille Certificate. An Apostille Certificate is certified by the U.S. Department of State as an Official Record. As an example, some countries require an Apostille Certificate when applying for a Visa.

Click here for a list of countries that may require an Apostille Certificate for your FBI Report. READ THE PAGE BEFORE ORDERING AN APOSTILLE CERTIFICATE.

Do not order the Apostille until
a. You have committed to employment in a country requiring an Apostille Certificate;
b. You have verified with the employer, U.S. Embassy or Consular that an Apostille Certificate is required. Go to https://travel.state.gov/content/travel/en/us-visas/visa-information-resources/list-of-posts.html.
- The FBI Report can only receive an Apostille Certificate within 90 days from the date of the report.
- You can contact us at (800) 445-8001 to order and pay for the Apostille Certificate Service after you have committed to employment in the country requiring the certificate, provided it is within the 90 day period.
- If you do not believe you will be able to gain commitment from the employer overseas or you do not believe you will make a decision within the 90 days from the date you place your order with SecurTest, place a cover letter with your fingerprints and information form that reads, “DO NOT SUBMIT MY FINGERPRINTS UNTIL SECURTEST INSTRUCTS.” You must email us at management@securtest.com when you wish the fingerprints to be submitted to the FBI. This will be your responsibility. You must also email an updated SECURTEST APPLICANT FINGERPRINT INFORMATION FORM if the country you will be employed is different from what you initially placed on the form. We will submit your fingerprints to the FBI once we receive your email authorization.
- Read our latest update before ordering the Apostille by Clicking Here.
FBI VISA AUTHORIZATION AND U.S. DEPARTMENT OF STATE APOSTILLE CERTIFICATION - ADD ON FEES - FOR U.S. CITIZENS ONLY.

1.) – Click if you require your FBI Report to have an Apostille Certificate from the U.S. Department of State - additional fee ($136.89) - You receive an electronic and mailed report and certificate. This may be required to obtain your VISA or in certain countries. This is an additional fee. SELECT THIS OPTION ONLY IF YOU HAVE BEEN HIRED IN A COUNTRY REQUIRING AN APOSTILLE CERTIFICATE.2.) I do not need an Apostille Certificate or I will contact SecurTest if one is required. (The additional fee must be paid if you order the certificate at a future date. You will be required to obtain a new FBI Report from SecurTest at the above-fees after 60 days from the date the FBI Report is issued. SELECT THIS OPTION IF YOU HAVE YET TO BE HIRED IN A COUNTRY REQUIRING AN APOSTILLE CERTIFICATE.
Calculation
Please Note: You will not be charged until payment is processed after you click "Submit" at the end. Be sure to carefully review your authorization before submitting.

USDDescription

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Please Carefully Complete the Following
The following information is required by courts, law enforcement agencies, and other entities for positive identification purposes when checking public, government or official records. It is confidential and will not be used for any other purposes.

You MUST answer each question.
Please enter the address where you will be for the next month if different than the address already entered.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Your Date of Birth*

MonthDayYear
Do you have a Social Security Number?*

YesNo

Your Social Security Number
Please only enter numbers (no dashes).

As part of International Background investigations, we are often prompted for additional information. Please carefully answer the questions below.
Your Father's Full Name
Your Mother's Full Name (including Maiden Name)
Please enter your Passport Number
Enter the Country that issued the Passport
Your Country of Citizenship
Your Current Physical Address (Not a PO Box) if different than above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long have you lived at this address? Please answer in months.
Do you have a different mailing address?*

YesNo
Mailing Address, if different than above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
1. Have you lived at another U.S. address within the past 10 years?*

YesNo

2. Next most recent Physical Address - (Must enter City and State at minimum)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long did you live at this address? Please answer in months.*
Have you lived at another U.S. address within the past 10 years where you were 18 or older?*

YesNo

3. Next most recent Physical Address - (Must enter City and State at minimum)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long did you live at this address? Please answer in months.*
Have you lived at another U.S. address within the past 10 years where you were 18 or older?*

YesNo

4. Next most recent Physical Address - (Must enter City and State at minimum)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long did you live at this address? Please answer in months.*
Have you lived at another U.S. address within the past 10 years where you were 18 or older?*

YesNo

5. Next most recent Physical Address - (Must enter City and State at minimum)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long did you live at this address? Please answer in months.*

Have you lived in a non-U.S. country within the past 10 years at the minimum age of 18 years or older and longer than 6 months?*

YesNo

First International Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long did you live at this address? Please answer in months.*
Have you lived in another non-U.S. country within the past 10 years at the minimum age of 18 years or older and longer than 6 months?

YesNo

Second International Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long did you live at this address? Please answer in months.*
2. Have you lived in another non-U.S. country within the past 10 years at the minimum age of 18 years or older?

YesNo

Third International Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long did you live at this address? Please answer in months.*
3. Have you lived in another non-U.S. country within the past 10 years at the minimum age of 18 years or older?

YesNo

Fourth International Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long did you live at this address? Please answer in months.*
4. Have you lived in another non-U.S. country within the past 10 years at the minimum age of 18 years or older?

YesNo

Fifth International Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long did you live at this address? Please answer in months.*

Contact Information
Your Email Address is REQUIRED*
example@example.com
Please confirm your Email Address*
example@example.com
Your phone number

Area CodePhone Number
Alternate phone number, or if not a United States line.

A Summary of Your Rights Under the Fair Credit Reporting Act
The FCRA notice will be attached to your email. You can read it here:

https://files.consumerfinance.gov/f/documents/bcfp_consumer-rights-summary_2018-09.pdf (English)

https://files.consumerfinance.gov/f/documents/bcfp_consumer-rights-summary_2018-09_es.pdf (Spanish)

FAIR CREDIT REPORTING ACT NOTICE
In accordance with the Fair Credit Reporting Act (FCRA, Public Law 91-508, Title VI), this information may only be used to verify a statement(s) made by an individual in connection with legitimate business needs. The depth of information available varies from state to state. The status of updates is available on request. Although SecurTest, Inc. has used reasonable methods and standards in its background screening and collection of information and every effort has been made to assure accuracy, SecurTest relies on sources of information which are outside of the control of SecurTest, as they are county, state, federal, and other official records. Final verification of an individual’s identity and proper use of report contents are the responsibility of the user of the report and the person ordering the report. SecurTest, Inc.’s policy requires purchasers of these reports to have signed a Service Agreement. This assures SecurTest, Inc., providers of official records, and SecurTest researchers, background screening investigators, and sources for such information that users of your report will abide by the FCRA and other legal obligations. If information contained in this report is responsible for disqualification, suspension or termination the requesting agency of this background report has agreed to give you immediate access to your SecurTest Report, iReviewNow, and your FCRA rights, among other required documentation.

By submitting my information, as the subject of the background check, I certify that I have received a copy of my FCRA Rights. I further affirm receipt of a copy of my SecurTest Background Report to the email provided and use of iReviewNow to verify the accuracy of the report.

I understand I can instantly review my report for FREE, identify errors or mistakes, report identity theft, dispute inaccuracies, provide comments using the iReviewNow Compliance System.
Signature - Use Your Mouse to Sign in the Box*

Clear

I am CURRENTLY a California Resident*

YesNo

California Disclosure Regarding Employment Background Report
The End User (Employer) may obtain from SecurTest, Inc.(“SecurTest”), 600 Grand Panama Blvd., Suite 202, Panama City Beach, FL 32407 (800) 445-8001 www.securtest.com,a consumer report and/or an investigative consumer report (“REPORT”) that contains background information about you in connection with your employment or employment application for employment purposes. If you are hired, to the extent permitted by law, organization may obtain from SecurTest further REPORTS throughout your employment for an employment purpose without providing further disclosure or obtaining additional consent.
The REPORT may contain information about your character, general reputation, personal characteristics and mode of living. The REPORT may include, but is not limited to, credit reports and credit history information; criminal and other public records and history; public court records (e.g., bankruptcies, tax liens and judgments); motor vehicle and driving records; educational and employment history, including professional disciplinary actions; drug/alcohol test results; and Social Security verification and address history, subject to any limitations imposed by applicable federal and state law. This information may be obtained from public record and private sources, including credit bureaus, government agencies and judicial records, former employers and educational institutions, and other sources.
If an investigative consumer REPORT is obtained, in addition to the description above, the nature and scope of any such REPORT will be employment verifications and references, or personal references.
You may inspect SecurTest’s files concerning you during normal business hours and upon reasonable notice. You can inspect the files at SecurTest’s offices if you furnish proper identification, and you can obtain a copy by paying duplication costs. One other person can accompany you if he or she furnishes reasonable identification. You can also obtain a copy of your files by sending SecurTest at the address listed above a written request, including proper identification, by certified mail. SecurTest will give you a summary of the information in the files by telephone if you submit a written request including proper identification. SecurTest has trained personnel who can explain the information furnished to you, and can provide a written explanation of any coded information contained in your files. “Proper identification” includes documents such as a valid driver’s license, Social Security card, military identification card or credit card. If necessary, SecurTest may request additional information about your employment and personal or family history to verify your identity.
I request to receive a copy of my report

Send me a copy.
Signature*

Clear

SecurTest California Safeguards: Pursuant to California laws, SecurTest does not report the following information, except where required by law or federal regulation:
- Report criminal records that did not result in a conviction.
- Report records of arrest, indictment, information, misdemeanor complaint, or conviction of a crime that, from the date of disposition, release, or parole, antedates the report by seven (7) years.
- Report records where it is found that a full pardon was granted or where the court sealed or expunged the record.
- Report criminal convictions involving Marijuana that is older than two (2) years from the date of conviction.
- Report criminal conviction involving possession, use, influence, paraphernalia, or presence during use of Marijuana that is older than two (2) years from the date of conviction.
We do not perform a credit check unless you have signed a seperate authorization.

I am CURRENTLY a Los Angeles, California resident.*

YesNo

Stand-alone Form - LA

City of Los Angeles CALIFORNIA

ERIC GARCETTI MAYOR

NOTICE TO APPLICANTS & EMPLOYEES FAIR CHANCE INITIATIVE FOR HIRING ORDINANCE

This Employer is subject to the Fair Chance Initiative for Hiring Ordinance (FCIHO) (LAMC 189.00).

THESE ARE YOUR RIGHTS…

1. Employers cannot inquire about or seek information about an Applicant’s Criminal History until after a Conditional Offer of Employment has been made to the Applicant*.

This includes job solicitations and applications or during any conversations or interviews
2. If an Employer decides to rescind an offer of employment based on information discovered during the criminal background check, the Employer is required to perform an Individualized Assessment.

Individualized Assessment - a written assessment that effectively links the specific aspects of the Applicant’s Criminal History with risks inherent in the duties of the Employment position sought by the Applicant.
If the offer is rescinded, the Applicant must receive:
o Written notification

o Copy of the Individualized Assessment, and

o Copies of any documentation used in the Employer’s decision

3. The Applicant has the right to the Fair Chance Process.

The Applicant has the opportunity to provide information or documentation to an Employer regarding the accuracy of his/her Criminal History or Criminal History Report or that should be considered in the Employer’s assessment, such as evidence of rehabilitation or other mitigating factors.
The Employer is required to hold the job open for at least five (5) days from the date notification of a rescinded offer of employment to allow an Applicant to submit such documentation, and, the Employer is required to review any documentation in order to reassess their decision.
FOR ADDITIONAL INFORMATION OR ASSISTANCE, CALL:

City of Los Angeles * Department of Public Works * Office of Contract Compliance * 1149 S. Broadway Street, Suite 300 * Los Angeles, CA 90015 * Phone: (844) WagesLA – Email: WagesLA@lacity.org

*Note: Not all Applicants/Employees are covered under the FCIHO. Please see ordinance (LAMC 189.00) for more details.

Form FCIHO, Rev. 12/16

==================================

City of Los Angeles CALIFORNIA

ERIC GARCETTI

MAYOR

AVISO PARA SOLICITANTES Y EMPLEADOS ORDENANZA DE LA INICIATIVA DE OPORTUNIDAD JUSTA PARA LA CONTRATACIÓN

Éste empleador está sujeto a la Ordenanza de la Iniciativa de Oportunidad Justa Para la Contratación (Fair Chance Initiative for Hiring Ordinance) (FCIHO) (LAMC 189.00).

ÉSTOS SON SUS DERECHOS…

1. Los empleadores no deben preguntar al solicitante sobre los antecedentes penales hasta despúes de que se le ha dado al solicitante una oferta condicional de empleo.

Ésto incluye solicitaciones y solicitudes de empleo o durante cualquier tipo de conversaciones o entrevistas
2. Si el empleador decide revocar la oferta de empleo como resultado de la investigación de antecedentes, el empleador está obligado a realizar una evaluación individualizada.

Evaluación Individualizada – Un análisis por escrito de las funciones y responsabilidades del trabajo, los antecedentes penales del solicitante, y cualquier otro factores que pueden afectar a la decisión de contratación.
Si se retiró la oferta, el solicitante debe recibir:Un aviso por escrito o Una copia de la evaluación individual, y
Copias de todos los documentos que el empleador utilizó a llegar a la decisión
3. El solicitante tiene el derecho al proceso de la Oportunidad Justa.

El solicitante tiene cinco (5) días desde la fecha cuando recibió el aviso de retiro de oferta para juntar y entregar documentos que muestra la prueba de rehabilitación y/o errores en la investigación de antecedentes. Se requiere que los empleadores examinen cualquier documentación presentada para reexaminar su decisión.

PARA MÁS INFORMACIÓN O ASISTENCIA, PUEDE LLAMAR A:

City of Los Angeles * Department of Public Works * Office of Contract Compliance * 1149 S. Broadway Street, Suite 300 * Los Angeles, CA 90015 * Phone: (844) WagesLA – Email: WagesLA@lacity.org

*Note: Not all Applicants/Employees are covered under the FCIHO. Please see ordinance (LAMC 189.00) for more details. Form FCIHO, Rev. 12/16

I am CURRENTLY a SanFrancisco, California resident.*

YesNo

Stand-alone Form - SF

CITY AND COUNTY OF SAN FRANCISCO

EDWIN M. LEE, MAYOR

NOTICE TO JOB APPLICANTS AND EMPLOYEES

San Francisco Fair Chance Ordinance Police Code, Article 49

Starting August 13, 2014, the Fair Chance Ordinance (San Francisco Police Code, Article 49) requires employers to follow strict rules regarding the use of arrest and conviction records in hiring and employment decisions. The ordinance covers job applicants and employees who would be or are performing work in whole, or in substantial part, in San Francisco and applies to employers who have 20 or more employees (regardless of the employees’ locations).

Certain matters are off-limits. An employer may never ask about, require disclosure of, or consider: an arrest not leading to a conviction (other than an unresolved arrest that is still undergoing criminal investigation or trial); participation in a diversion or deferral of judgment program; a conviction that has been expunged or made inoperative; any determination in the juvenile justice system; a conviction more than 7 years old; and a criminal offense other than a felony/misdemeanor. Matters that are off-limits cannot be used by the employer for any reason at any stage of the hiring process.

An employer cannot ask about an individual’s conviction history or unresolved arrests at the start of the hiring process. This includes through a job application form, informal conversation, or otherwise.

A mandatory interactive process for matters not off-limits. Only after a live interview has been conducted, or a conditional offer of employment made, is the employer allowed to ask about an individual’s conviction history (except as to matters that are off-limits) and unresolved arrests. Only those convictions and unresolved arrests that directly relate to the individual’s ability to do the job may be considered in making an employment decision.

Before the employer may take an adverse action such as failing/refusing to hire, discharging, or not promoting an individual based on a conviction history or unresolved arrest, the employer must give the individual an opportunity to present evidence that the information is inaccurate, the individual has been rehabilitated, or other mitigating factors. The individual has seven days to respond, at which point the employer must delay any adverse action for a reasonable time and reconsider the adverse action. The employer must notify the individual of any final adverse action.

Evidence of rehabilitation include satisfying parole/probation; receiving education/training; participating in alcohol/drug treatment programs; letters of recommendation; and age at which the individual was convicted. Mitigating factors include coercion, physical or emotional abuse, and untreated substance abuse/mental illness, that contributed to the conviction.

Preemption. Where federal or state law imposes a criminal history requirement that conflicts with a requirement of the Fair Chance Ordinance, the federal or state law will apply.

No Retaliation. An employer may not take an adverse action against an applicant or employee for exercising their rights under the ordinance or cooperating with the Office of Labor Standards Enforcement OLSE.

If you need more information, or wish to report an employer that you believe has violated this ordinance, please contact the OLSE at 415-554-5192 or email FCE@sfgov.org.

OFFICE OF LABOR STANDARDS ENFORCEMENT City Hall, Room 430 1 Dr. Carlton B. Goodlett Place San Francisco CA 94102-4685 Tel. (415) 554-6235 Fax (415) 554-4791

====

Publicar donde esté accesible para quienes solicitan el empleo y los empleados. CIUDAD Y CONDADO DE SAN FRANCISCO

EDWIN M. LEE, ALCALDE

AVISO PARA LOS SOLICITANTES DE EMPLEO Y EMPLEADOS

Ordenanza de Oportunidades Equitativas de San Francisco

Código de Policía, Artículo 49

A partir del 13 de agosto de 2014, la Ordenanza de Oportunidades Equitativas (Código Policiaco de San Francisco, Artículo 49) requiere que los empleadores sigan reglas estrictas referentes al uso de los expedientes de arrestos y condenas al tomar decisiones de contratación y empleo. La ordenanza cubre a los solicitantes de empleos y empleados que estarían o están realizando su trabajo, o una parte sustancial del mismo, en San Francisco y se aplica a los empleadores que tengan 20 o más empleados (sin importar la ubicación de los empleados).

Está prohibido tocar ciertos asuntos. Un empleador nunca puede preguntar, requerir la divulgación de, o considerar: un arresto que no haya resultado en una condena (que no sea un arresto no resuelto que actualmente esté bajo investigación penal o juicio); participación en un programa de justicia alternativa o de fallo diferido; una condena que haya sido cancelada o declarada inoperante; cualquier determinación en el sistema de justicia juvenil; una condena de más de 7 años de antigüedad; y una infracción penal que no sea un delito mayor o delito menor. El empleador no puede utilizar los asuntos que están prohibidos para ningún propósito, en ninguna etapa del proceso de contratación.

Un empleador no puede preguntar sobre el historial de condenas o de arrestos no resueltos de una persona al inicio del proceso de contratación. Esto incluye preguntar mediante un formulario de solicitud de empleo, una conversación informal o de otra forma.

Un proceso interactivo obligatorio para asuntos que no estén prohibidos. Sólo después de que se haya hecho una entrevista en persona, o se haya hecho una oferta condicional de empleo, el empleador tiene permitido hacer preguntas sobre el historial de condenas de una persona (excepto sobre asuntos que estén prohibidos) y arrestos no resueltos. Sólo se pueden tomar en cuenta las condenas y los arrestos no resueltos que directamente se relacionen con la capacidad de la persona para hacer el trabajo al tomar la decisión del empleo.

Antes de que el empleador pueda tomar una acción adversa como no contratar, negarse a contratar, despedir, o no dar un ascenso a una persona con base en su historial de condenas o arrestos no resueltos, debe darle a la persona una oportunidad para presentar evidencia de que la información no es precisa, que la persona está rehabilitada, y otros factores atenuantes. La persona tiene 7 días para responder, en cuyo momento, el empleador debe posponer cualquier acción adversa durante un tiempo razonable y reconsiderar la acción adversa. El empleador debe avisar al individuo sobre cualquier acción adversa final.

La evidencia de rehabilitación incluye una libertad probatoria/bajo palabra satisfactoria; recibir educación/capacitación; participación en programas de tratamiento contra alcohol/drogas; cartas de recomendación; y la edad a la que la persona recibió la condena. Los factores atenuantes incluyen el chantaje, el maltrato físico o emocional, y la enfermedad no tratada mental o de consumo de sustancias que hayan contribuido con la condena.

Aplicación preferente. Cuando la ley federal o estatal impone un requisito de historial criminal que entra en conflicto con algún requisito de la Ordenanza de Oportunidades Equitativas, prevalecerá la ley federal o estatal.

Sin represalias. Un empleador no puede tomar una acción adversa contra un solicitante o empleado por ejercer sus derechos conforme a la ordenanza o por cooperar con la Oficina de Cumplimiento de los Estándares Laborales (Office of Labor Standards Enforcement, OLSE).

Si usted necesita más información, o si desea reportar a un empleador que usted crea que ha infringido esta ordenanza, por favor comuníquese con la OLSE al 415-554-5192 o por correo electrónico a FCE@sfgov.org.

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張貼於求職者和雇員容易看到的地方。三藩市縣市長李孟賢求職者和雇員通告三藩市公平機會條例《警察法規》第 49 條

2014年8月13日起，《公平機會條例》（《三藩市員警法規》第49條》）要求雇主做出招聘和雇用決定時嚴格遵守使用被捕和犯罪記錄相關的規定。。本條例適用於將來或目前大部分時間在三藩市工作的求職者和雇員並適用於有20名或以上雇員的雇主（不考慮雇員的所在地）。

某些事項受到禁止。雇主任何時候不得問及、要求披露或者考慮求職者或雇員相關的以下事項：（1）未導致定罪的逮捕（仍在進行刑事調查或審理的除外）；（2）參與判決程序轉移或延期；（3）被刪除或宣告無效的有罪判決；（4）青少年司法系統的決定；（5）7年前的有罪判決；以及（6）重罪/輕罪以外的犯罪行為。

雇主在招聘過程開始時，不得問及個人的犯罪史或未定罪的逮捕。這包括透過職位申請表、非正式談話或其他方式的詢問。

不受禁止事項在聘用過程中必須遵守的規定。。僅可在進行現場面試或者提供有條件雇用之後，才准許雇主問及個人的定罪史（受到禁止的事項除外）和未定罪的逮捕。做出雇用決定時僅可考慮與個人從事該工作的能力直接相關的有罪判決和未定罪的逮捕。

雇主根據定罪史或未定罪的逮捕採取不/拒絕聘用、解雇或不晉升個人之前，雇主必須給予此人機會提交證據表明該資訊不準確、此人已改過自新或者其他減輕因素。此人有七天時間做出回應，在此期間雇主必須合理延遲時間並重新考慮該不聘佣決定。雇主必須通知此人任何最終的決定。

改過自新的證據包括令人滿意的假釋/緩刑；接受教育/培訓；參加酒精/毒品治療項目；推薦信；以及個人被判有罪的年齡。減輕因素包括促成有罪判決的脅迫、身體或精神虐待以及未得到治療的藥物濫用/精神疾病。

優先適用。如果聯邦或州法律規定的犯罪記錄要求與《公平機會條例》的要求互相衝突，則將適用聯邦或州法律。

禁止報復。雇主不得因求職者或雇員行使條例規定的權利或者配合勞工標準執行辦公室（OLSE），而對求職者或雇員採取報復行動。

如果您需要更多資訊或者想要舉報您認為違反本條例的雇主，請撥打415-554-5192或者發送電子郵件到FCE@sfgov.org聯繫OLSE。

I am a CURRENT resident of the State of New York Resident*

YesNo

NEW YORK DISCLOSURE AND RELEASE
In connection with my application for employment (including contract for services) with the Employer.

I understand that consumer reports which may contain public record information and investigative consumer reports consisting of interviews with employers, neighbors, friends, and associates may be requested from SecurTest, Inc., a consumer reporting agency. These reports may include the following types of information: names of employers and dates of previous employment, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers’ compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records. I hereby consent to your obtaining the above information from such agency.

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THE CONSUMER REPORTING AGENCY TO FURNISH THE ABOVE-MENTIONED INFORMATION.

I have the right to make a request to SecurTest, Inc upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me which the agency has previously furnished within the two year period preceding my request.

I hereby authorize procurement of consumer report(s). If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports and investigative consumer reports at any time during my employment (or contract) period.

I acknowledge receipt of a copy of Article 23-A of New York Correction Law.

New York State Labor Law §201-f provides that every employer shall post, in a place accessible to his or her employees, a copy of Correction Law Article 23-A relating to the licensure and employment of persons previously convicted of one or more criminal offenses.

I am a CURRENT resident of New York City (Manhattan, Brooklyn, Queens, The Bronx, Staten Island.*

YesNo

Stand-alone Form - NYC

Notice Regarding Credit Checks Per City of New York Law

In conjunction with my application for employment with the Client, I understand that the Client intends to obtain information for employment screening purposes from a consumer reporting agency (CRA). I understand that a consumer report may be obtained from the following CRA: SecurTest, Inc., 600 Grand Panama Blvd, Suite 202, Panama City Beach, FL 32407; tel. # 800.445.8001; www.securtest.com. A copy of their privacy policy may be requested. Pursuant to the city of New York administrative code Section 8-102, subdivision 29, the Client informs you that it may obtain a credit report about you from the above named CRA because you are seeking employment in the following position(s), or for the following reason(s):

A position with (i) signatory authority over third party funds or assets valued at $10,000 or more, or (ii) fiduciary responsibility to the employer and authority to enter into financial agreements valued at $10,000 or more on behalf of the employer;
A position with regular duties allowing an employee to modify digital security systems designed to prevent the unauthorized use of the employer’s or client’s networks or databases;
A non-clerical position with regular access to trade secrets or national security/intelligence information;
The employer is required to use an individual’s consumer credit history for employment purposes under state or federal law/regulations or by a self-regulatory organization (as defined by the Securities Exchange Act of 1934);
A position as a police officer or peace officer, or various positions with a law enforcement or investigative function at the Department of Investigation or subject to background investigation by the Department of Investigation;
A position requiring bonding under federal, state, or city law (e.g., certain positions in finance);
A position requiring security clearance under federal or any state law.
I acknowledge receipt of the Notice Regarding Credit Checks Per New York City Law and A Summary of Your Rights Under the Fair Credit Reporting Act and certify that I have read and understand these documents. I further acknowledge that a telephonic facsimile (FAX) or photographic copy of this authorization shall be as valid as the original.

SecurTest does not obtain your credit report unless you complete a seperate authorization where the employer has identified one of the above requirements.

I am a CURRENT resident of Wisconsin.*

YesNo

Stand-alone Form - WI

Wisconsin Consumers Have the Right to Obtain a Security Freeze

Effective January 1, 2007, if you live in Wisconsin you have a right to place a "security freeze" on your credit report. A freeze will prohibit a credit reporting agency from releasing information in your credit report without your express authorization. A security freeze must be requested in writing by certified mail by you to each of the three consumer reporting agencies. The security freeze is designed to prevent an extension of credit, such as a loan or a new credit card, from being approved in your name without your consent. A freeze may protect you from identity theft. However, you should be aware that using a security freeze to take control over who gets access to the personal and financial information in your credit report may delay approval of any subsequent request or application you make regarding a loan, credit, mortgage, or Internet credit card transaction, including an extension of credit at point of sale. As a result, if you plan on obtaining new credit, you should release your freeze approximately one week before seeking new credit.

Placing the Freeze on your Credit Report

To place a security freeze on your credit report, send your written request via certified mail to:

Equifax CSC Credit Services Security Freeze P O Box 674438 Houston, TX 77267-4438

Experian Experian Security Freeze P. O. Box 9554 Allen, TX 75013

TransUnion TransUnion Security Freeze P. O. Box 6790 Fullerton, CA 92834-6790

The fee to place a security freeze is $10.00 for each credit reporting agency. If you submit a copy of a valid police report that verifies you are a victim of identity theft, no fee will be charged. Include your complete name, complete address, social security number, date of birth and payment, if applicable. For your convenience there are form letters to each of the credit reporting companies available on www.privacy.wi.gov. The forms allow you to type in your personal information and print the letter or you may print the blank letter and write your information Written confirmation of the security freeze will be sent to you within 10 business days of receipt of the request.. It will include a personal identification number (PIN), and instructions for removing the security freeze or authorizing the release of your credit report for a specific period of time.

Removing the Freeze from your Credit Report

When you request a security freeze for your credit report, you will be provided a personal identification number (PIN) to use if you choose to remove the security freeze from your credit report or authorize the release of your credit report for a period of time after the security freeze is in place. Be sure to keep your personal identification number (PIN) in a secure place for use when needed. To remove your freeze either permanently or temporarily, you must contact the consumer reporting agency and provide all of the following:

(1) The personal identification number (PIN). (2) Proper identification to verify your identity. (3) The period of time for which the report shall be made available. (4) Payment of the appropriate fee.

A security freeze does not apply to those with which you have an existing account that request information in your credit report for the purposes of reviewing or collecting the account. Reviewing the account includes activities related to account maintenance, monitoring, credit line increases, and account upgrades and enhancements.

If You Are a Victim of Identity Theft

A victim of identity theft with a police report to verify the crime will not be required to pay the $10 fee to the credit reporting agencies in order to obtain a security freeze. Be prepared to submit a copy of the police report when requesting the freeze. No fee will be charged to remove or replace the freeze as long as the police report is included in all correspondence.

If you believe your identity has been stolen, contact the Wisconsin Office of Privacy Protection at 1-800-422-7128 or email us at WisconsinPrivacy@datcp.state.wi.us. Visit our website at privacy.wi.gov for more information.

I am a CURRENT resident of the State of Washington.*

YESNO

Stand-alone Form - WA

STATE OF WASHINGTON CONSUMER CREDIT REPORTING ACT

SUMMARY OF CONSUMER RIGHTS

The State of Washington Fair Credit Reporting Act (WFCRA) 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 WFCRA. The WFCRA is modeled after the Federal Fair Credit Reporting Act. The same rights are provided under the Federal Fair Credit Reporting Act and you have received A Summary of Your Rights Under the Federal Fair Credit Reporting Act. You can get the complete text of WFCRA RCW 19.182, from the Washington Code Revisers Office, P.O. Box 40551, Olympia, WA, 98504, or online at http://apps.leg.wa.Gov/rcw/default.aspx?cite=19.182&full=true#19.182.070.

• You must be told if information in your file has been used against you. If a person takes an adverse action against you that is based, in whole or in part, on information contained in a consumer report, that person must tell you, and must give you the name, address, and telephone number of the consumer reporting agency that provided the information.

• You have a 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, although medical information may be withheld and given directly to your medical provider. You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You will not be charged for:

a consumer report if a person has taken adverse action against you because of information in your credit report;
the reinvestigation of information you dispute; or
corrected reports resulting from the deletion of inaccurate or unverifiable information.
In addition, you are entitled to one free consumer report every 12 months, upon request. You may be charged a limited fee for a second or subsequent report requested by you during a 12 month period.

• You have a right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and you notify the consumer reporting agency directly of the dispute, the consumer reporting agency will reinvestigate without charge and record the current status of the disputed information before the end of thirty business days, unless your dispute is frivolous.

• Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Upon completion of the reinvestigation, if the information you disputed is found to be inaccurate or cannot be verified, the consumer reporting agency will delete the information and notify you of the correction.

If the reinvestigation does not resolve your dispute, you may file with the consumer reporting agency a brief statement setting forth the nature of your dispute. The statement will be placed in your consumer file and in any subsequent report containing the information you disputed.

• 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 ten years old.

• 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 WFCRA specifies those with a valid need for access.

• You must be notified if reports are provided to employers. A consumer reporting agency may not give out information about you to employers without your knowledge. A potential employer must make a clear and conspicuous disclosure in writing to you or obtain your consent before obtaining a report. A current employer may not receive a report unless it has given you written notice that consumer reports may be used for employment purposes.

• You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. You may elect not to receive unsolicited “prescreened” offers for credit and insurance by using the consumer reporting agency’s notification system to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).

• You may place a security freeze on your credit report. A security freeze prevents your credit file from being shared with potential creditors or insurance companies. You may request a security freeze by contacting the three credit bureaus, as follows: They may charge a fee for providing this service.

Equifax — 1-800-349-9960

Experian — 1‑888‑397‑3742

TransUnion — 1-888-909-8872

TransUnion LLC P.O. Box 2000 Chester, PA 19016

https://freeze.transunion.com

Experian Security Freeze P.O. Box 9554 Allen, TX 75013

www.experian.com/freeze

Equifax Security Freeze P.O. Box 105788 Atlanta, GA 30348

https://www.freeze.equifax.com

You may also contact SecurTest, Inc., the background screening provider, at (800) 445-8001 or by mail at 600 Grand Panama Blvd, Suite 202, Panama City Beach, FL 32407. SecurTest only provides the credit reports as reported by the credit bureaus.

• You may be able to block information resulting from identity theft from appearing on your credit report. If you are a victim of identity theft, a consumer reporting agency must permanently block misinformation resulting from that theft from appearing on your credit report. You must provide the consumer reporting agency with a copy of a police report as evidence of your claim before it can place the block on your report.

• 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 WFCRA, you may be able to sue in state or federal court.

COMPLAINTS

Any complaints by consumers under state law may be directed to:

Office of the Attorney General

Consumer Protection Division

800 5th Avenue, Suite 2000

Seattle, Washington 98104-3188

Phone 1-800-551-4636 or (206) 464-6684 * Fax (206) 389-2801 * Statewide Toll-Free TDD: 800 276-9883

Complaints May Be Made Via U.S. Mail or E-Mail .

Complaints: http://www.atg.wa.gov/FileAComplaint.aspx

(Include your U.S. Mail address with any complaint.)

Website & Forms: http://www.atg.wa.gov/

I am a CURRENT resident of Vermont.*

YESNO

Stand-alone Form - VT

NOTICE REGARDING CREDIT CHECKS PER VERMONT LAW

Pursuant to Vermont Act No. 154 (S. 95), the Client informs you that it may obtain a credit report about you, for the following reason(s):

[_] The information is required by state or federal law or regulation;

[_] You seek to be/are employed in a position that involves access to “confidential financial information” (defined as “sensitive financial information of commercial value that a customer or client of the employer gives explicit authorization for the employer to obtain, process, and store and that the employer entrusts only to managers or employees as a necessary function of their job duties”);

[_] The Client is a financial institution as defined in 8 V.S.A. §11101(32) or a credit union as defined in 8 V.S.A. §30101(5);

[_] You seek to be/are employed in a position as a law enforcement officer, emergency medical personnel or firefighter as these terms are respectively defines in 20 V.S.A. §2358, 24 V.S.A. §2651(6) and 20 V.S.A. §3151(3)

[_] You seek to be/are employed in a position that requires a financial fiduciary responsibility to the Client or a Client’s clients, including the authority to issue payments, collect debts, transfer money or enter into contracts;

[_] You seek to be/are employed in a position that involves access to the Client’s payroll information;

[_] The Client can demonstrate that credit information is a valid and reliable predictor of employee performance in the your specific position of employment;

[✔] The Client will not obtain a consumer credit report on you.

Are you a CURRENT resident of New Jersey?*

YESNO

Stand-alone Form - NJ

A Summary of Your Rights Under New Jersey’s Fair Credit Reporting Act

Under the New Jersey Fair Credit Reporting Act (NJFCRA or the “Act”), an employer, before taking adverse employment action, is required to provide the applicant or employee with a summary of their rights under the Act with respect to consumer reports or investigative consumer reports obtained for employment purposes from a consumer reporting agency (CRA). This Summary is intended to serve that purpose.

You can find the complete text of the NJCRA, N.J. Stat. §§56:11-29 – 56:11-41, at the New Jersey State Legislature’s web site (http://www.njleg.state.nj.us/). You may have additional rights under the federal Fair Credit Reporting Act, 15 U.S.C. 1681-1681u, which is available on the Internet at the Federal Trade Commission’s website (http://www.ftc.gov).

• You must consent to the procurement for employment purposes of a report about you. Before an employer can obtain a report about you from a CRA, the employer must provide you with notice that it will request the report and obtain your consent to that request. A CRA may not give out information about you to the employer, or prospective employer, without your written consent.

• You must be told if information in your file has been used against you for employment purposes. An employer who uses information from a consumer or investigative consumer report to take action against you -- such as denying an application for employment or terminating employment -- must tell you that its decision is based in whole or in part on the report. The employer also must provide you with a description of your rights under the NJCRA and a reasonable opportunity to dispute with the CRA any information on which the employer relied.

• You have a right to know what is in your file. You may request and obtain all the information about you in the file of a CRA and a list of everyone who has recently requested your file. These disclosures may be made in person, over the telephone or by any other reasonable method available to the CRA. Additionally, you are entitled to one free consumer report every 12 months, upon request. You may be charged a limited fee for a second or subsequent report requested by you during a 12 month period.

• You have a right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and you notify the consumer reporting agency directly of the dispute, the CRA will reinvestigate without charge and record the current status of the disputed information before the end of thirty business days, unless your dispute is frivolous or irrelevant. The CRA must give you a written report of the investigation.

• Consumer reporting agencies must correct or delete inaccurate, incomplete or unverifiable information. Upon completion of the reinvestigation, if the information you disputed is found to be inaccurate or cannot be verified, the CRA will delete the information within 30 days after you dispute it and notify you of the correction. If the reinvestigation does not resolve your dispute, you may file with the CRA a brief statement setting forth the nature of your dispute. The statement will be placed in your consumer file and in any subsequent report containing the information you disputed.

• Consumer reporting agencies may not report outdated negative information. In most cases, a CRA may not report negative information that is more than seven years old, or bankruptcies that are more than ten years old.

• You may place a security freeze on your credit report. A security freeze prevents your credit file from being shared with potential creditors or insurance companies. You may request a security freeze by contacting by calling the following toll-free telephone number(s): TransUnion: 888-909-8872, Experian: 888-397-3742, Equifax: 800-685-1111 (NY residents please call 1-800-349-9960). TransUnion, Experian and Equifax can also be reached at the following addresses:

TransUnion LLC
P.O. Box 2000
Chester, PA 19016
https://freeze.transunion.com

TransUnion — 1-888-909-8872
Experian Security Freeze
P.O. Box 9554
Allen, TX 75013
www.experian.com/freeze

Experian — 1‑888‑397‑3742
Equifax Security Freeze
P.O. Box 105788
Atlanta, GA 30348
https://www.freeze.equifax.com
Equifax — 1-800-349-9960

A fee may be charged for providing this service.

• You may seek damages from violators. If a CRA, or in some cases, a user of consumer reports or a furnisher of information to a CRA violates the NJFCRA, you may be able to sue in state court.

COMPLAINTS

DIVISION OF CONSUMER AFFAIRS
Department of Law and Public Safety
124 Halsey Street
Newark, NJ 07102
Phone: 800-242-5846
973-504-6200

I am a current resident of Minnesota.*

YesNo

Notification of Rights for Minnesota Consumers

Minnesota Notice: SecurTest will perform criminal history records pursuant to Minnesota Statutes §13.87, sub-division 3(f). Please click on the following links for more information about your rights:
https://www.revisor.mn.gov/statutes/cite/13.87, which is Minnesota Statutes §13.87, subdivision 3(f). Information on Minnesota state law governing the timing of pre-employment background checks is available from the Minnesota Department of Human Rights at https://mn.gov/mdhr/employers/criminal-background/.
Stay of Imposition: This means the defendant pled guilty to a felony count. However, upon successful completion of probation, the conviction is reduced to Misdemeanor.

Notification of Rights for Minnesota Consumers Security Freeze Process

If you are a Minnesota resident, you have the right to place a “security freeze” on your credit report, which will prohibit us from releasing any information in your credit report without your express authorization, except to those with whom you have an existing account or a collection agency acting on behalf of the existing account, for purposes of reviewing (account maintenance, monitoring, credit line increases and account upgrades and enhancements) or collecting the account. Your information also may be used for the purposes of prescreening as provided for by the federal Fair Credit Reporting Act, even if a security freeze is on the report. A security freeze is designed to prevent credit, loans, and services from being approved in your name without your consent; however, using a security freeze may delay, interfere with, or prohibit the timely approval of any subsequent requests or applications regarding a new loan, credit, mortgage, insurance, government services or payments, rental housing, employment, investment, license, cellular phone, utilities, digital signature, Internet credit card transaction, or other services, including an extension of credit at point of sale.

To request a security freeze send all of the following via certified mail to:

• Equifax Security Freeze P.O. Box 105788 Atlanta, GA 30348

• Experian Security Freeze P.O. Box 9554 Allen, TX 75013

• TransUnion Security Freeze P O Box 2000 Chester, PA 19016

You must include your full name, with middle initial and generation, such as JR, SR, II, III, etc.; Social Security number; date of birth (month, day and year); current address and previous addresses for the past two years; and if applicable, a valid investigative report, a valid incident report, or a valid complaint or valid case number documenting identity theft with a law enforcement agency or the Department of Motor Vehicles (DMV). In addition, enclose one copy of a government issued identification card, such as a driver’s license, state ID card, etc., and one copy of a utility bill, bank or insurance statement, etc., and make sure that each copy is legible (enlarge if necessary), displays your name and current mailing address, and the date of issue (statement dates must be recent). We are unable to accept credit card statements, voided checks, lease agreements, magazine subscriptions or postal service forwarding orders as proof. Copies of any documents should be sent, and you should always retain your original documents.

I am a current resident of Massachusetts.*

YesNo

MASSACHUSETTS NOTICES

CONCERNING THE PROCESS IN CORRECTING A CRIMINAL RECORD

1.   If you have undergone a background check by an agency that has received a criminal record from the DCJIS, you may ask the agency to provide you with a copy of the criminal record. You may also request a copy of your adult criminal record from the Department of Criminal Justice Information Services, 200 Arlington Street, Suite 2200, Chelsea, MA02150 or by calling (617)660-4640 or go to http://www.mass.gov/Eeops/docs/cjis/cori_request_personal.pdf

2. The DCJIS charges $25.00 fee to provide an individual with a copy of his/her criminal record. You may complete an affidavit of indigency and request that the DCJIS waive the fee.

3.   Upon receipt, review the record. If you need assistance in interpreting the entries or dispositions, please review the disposition code and “how to read a criminal record” on the DCJIS website www.mass.gov/cjis/cori/cori_bop.html

4. The DCJIS does not offer “walk-in” service but you may call our Legal Division at (617)660-4760 for assistance or the CARI Unit of the Office of the Commissioner of Probation at (617)727-5300.

5. If you believe that a case is opened on your record that should be marked closed, you may contact the Office of the Commissioner of Probation Department at the court where the charges were brought and request that the case(s) be updated.

6. If you believe that a disposition is incorrect, contact the Chief Probation Officer at the court where the charges were brought or the CARI Unit at the Office of the Commissioner of Probation and report that the court incorrectly entered a disposition on your criminal record.

7.   If you believe that someone has stolen or improperly used your identity and were arraigned on criminal charges under your name, you may contact the Office of the Commissioner of Probation CARI Unit or the Chief Probation Officer in the court where the charges were brought. For a listing of courthouses and telephone numbers please see www.mass.gov/cjis/cori/cori_codes_court.html

8. In some situations of identity theft, you may need to contact the DCJIS to arrange to have fingerprints analysis conducted.

9. If there is a warrant currently outstanding against you, you need to appear at the court and ask that the warrant be recalled. You cannot do this over the telephone.

10. If you believe that an employer, volunteer agency, housing agency or municipality has been provided with a criminal record that does not pertain to you, the agency should contact the CORI Unit for assistance at (617)660-4640.

MASSACHUSETTS: If you submit a request to us in writing, you have the right to know whether the Company ordered an investigative consumer report from SecurTest, Inc., which may include any or all of the following: criminal history review, driving record review, credit report review, and employment/education verifications. You may inspect and order a free copy of the report by contacting ADP Screening and Selection Services.

NOTICE EMPLOYERS MUST PROVIDE PER MASSACHUSETTS LAW

An applicant for employment with a record expunged pursuant to section 100F, section 100G, section 100H or section 100K of chapter 276 of the General Laws may answer ‘no record’ with respect to an inquiry herein relative to prior arrests, criminal court appearances or convictions. An applicant for employment with a record expunged pursuant to section 100F, section 100G, section 100H or section 100K of chapter 276 of the General Laws may answer ‘no record’ to an inquiry herein relative to prior arrests, criminal court appearances, juvenile court appearances, adjudications or convictions.

FAIR CREDIT REPORTING ACT NOTICE

In accordance with the Fair Credit Reporting Act (FCRA, Public Law 91-508, Title VI), this information may only be used to verify a statement(s) made by an individual in connection with legitimate business needs. The depth of information available varies from state to state. Status of updates is available on request. Although SecurTest, Inc. has used reasonable methods and standards in its background screening and collection of information and every effort has been made to assure accuracy, SecurTest relies on sources of information which are outside of the control of SecurTest, as they are county, state, federal, and other official records. Final verification of an individual’s identity and proper use of report contents are the responsibility of the person ordering this report or the End User of the report. SecurTest, Inc.’s policy requires purchasers of these reports to have signed a Service Agreement. This assures SecurTest, Inc., providers of official records, and SecurTest researchers, background screening investigators, and sources for such information that users of your report will abide by the FCRA and other legal obligations. If information contained in this report is responsible for disquali cation, suspension or termination the requesting agency of this background report has agreed to give you immediate access to your SecurTest Report, iReviewNow, and your FCRA rights, among other required documentation.

By submitting my information, as the subject of the background check, I certify that I have received a copy of my FCRA Rights. I understand I can instantly review my report for FREE, identify errors or mistakes, report identity theft, dispute inaccuracies, provide comments using the iReviewNow Compliance System.

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

The CLIENT identified on the first page (“the Client”) may obtain information about you from a third party consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding you credit history, criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment history, or other background checks.

You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you and to request a copy of your report. These searches will be conducted by SecurTest, Inc., 600 Grand Panama Blvd, Suite 202, Panama City Beach, FL 32407; tel. # 800.445.8001; www.securtest.com. The scope of this disclosure is all-encompassing, however, allowing the Client to obtain from any outside organization all manner of consumer reports throughout the course of your employment to the extent permitted by law.
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I hereby authorize iReviewNow, LLC and SecurTest, Inc. to transmit a copy of my background report to me in a secure electronic manner. I understand that receiving a copy of my report, use of iReviewNow, or providing responses or disputes using iReviewNow is a free service, which allows me instant access and other valuable benefits described in the Terms and Conditions found at iReviewNow.com and below. I FURTHER AUTHORIZE iReviewNow, LLC and SecurTest to transmit a copy of my background report, including any FBI Report, to a prospective employer.*

I agree to the iReviewNow, LLC and SecurTest, Inc. terms and conditions.
INSTRUCTIONS FOR REQUESTING A COPY OF YOUR REPORT AT A FUTURE DATE:

You may go to iReviewNow.com to request a copy of your report in the future. You will be required to upload, scan color copies of your government issued identification, such as a driver’s license, state identification card, passport, birth certificate, or similar documentation to verify your identity. WE MUST HAVE YOUR DATE OF BIRTH, SOCIAL SECURITY NUMBER (where issued), ADDRESS, AND EMAIL TO FIND AND SEND YOU A COPY OF YOUR REPORT.
HOW TO CONTACT SECURTEST, INC.

SecurTest, Inc. ★ 600 Grand Panama Blvd. Ste. 202, Panama City Beach, FL 32407★ (800) 445-8001 (toll-free to speak to SecurTest) ★ Fax (866) 580-4851 ★ compliance@securtest.com ★ compliance@iReviewNow.com ★ or by going to www.iReviewNow.com

I hereby authorize SecurTest, Inc. and iReviewNow, LLC (not a consumer reporting agency) and its assigns to transmit my background report, including any FBI Rap Sheet, U.S. Consumer or Investigative Reports, and/or International Background Reports, or other background reports (collectively "Report"), to me and any other entity I may authroize in writing by email ollowing my receipt, review and approval of my completed Report via iReviewNow. I release and forever hold harmless SecurTest, Inc. and iReviewNow, LLC for releasing any or all of my background report or reports and my iReviewNow responses. SecurTest, and iReviewNow do not make hiring decisions or recommendations. All employment or placement decisions are solely the responsibility of the employer.
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Please Note: After clicking Submit on the following page, payment will be processed according to the screenings and jurisdictions you selected on Page 5. You are encouraged to double check this to ensure that your order is accurate and you will be charged the correct amount.

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You are almost finished! This is the last page of the authorization. After you have read and signed the following, click "Submit" at the bottom of the page.
BACKGROUND CHECK AUTHORIZATION

I hereby agree, authorize and consent to the preparation of consumer reports and investigative consumer reports ("Background Reports") about me by SecurTest, Inc., a consumer reporting agency. I further authorize and consent to the procurement of Background Reports about me by the "Employer", which I understand may contain information about my criminal history, character, general reputation, personal characteristics, and/or mode of living.

I authorize SecurTest, Inc., subject to any applicable laws protecting my privacy, to collect various types of information to prepare a background report that may include, but are not limited to domestic and international criminal records, sex offender databases, employment records, education records, professional credential and license records, department of motor vehicle records ("driving records"), military records, professional and personal references, government sanctions and exclusions databases, and where it applies to the position DOT regulated employer records in compliance with 49 CFR 382.

I authorize any local, state, federal or international law enforcement agency, public or private agency, administrator, public or private institution, public or private school or university, information services bureau, employer, insurance company, credit bureaus, or any other party holding information under my name to furnish any and all background
information requested by SecurTest for the purpose of providing a background report to the “Employer”.

I agree, authorize and consent to the release and disclosure of any and all information about me by SecurTest to the “Employer”, and where “Employer” is pursuing my direct or temporary engagement with a third party, Company may provide that third party with a copy of my Report.

I hereby authorize SecurTest to provide me with any notices, including those required by federal, state or local laws, on behalf of itself or at the mailing address(es) and/or email address(es) I have provided to SecurTest and/or to the “Employer, its client.

This authorization electronically or physically signed by me shall be valid as allowable by law without my further authorization from the date of execution and throughout my engagement with the Employer. I agree that a copy of this document by fax or other electronic means shall be as valid as the original.
INSTANT ABILITY TO REVIEW YOUR REPORT.

How You Benefit:
- You have an opportunity to see the contents of your background report prior to, at the same time, or near the same time as the Company who you authorized to receive your report at iReviewNow.com or by email.
- You have an immediate opportunity to make sure the report is accurate, complete and up to date, and dispute any information you believe to be incomplete or inaccurate. You have an immediate opportunity to provide an explanation for any information contained in the report, especially information about your past, and provide any mitigating circumstances that may assist the Company receiving your background report with any decisions based upon your report.
I agree to the following terms and conditions.

1.       I certify that the information provided on the Background Information Form is my personal identifying information and is accurate and complete.

2.       I agree to review the consumer report about me for accuracy and completeness by exclusively using www.iReviewNow.com (hereafter “iReviewNow) as provided by iReviewNow, LLC. I agree to go to iReviewNow.com to view my report, answer the iReviewNow questions, and dispute any inaccurate or incomplete information.. I agree to contact SecurTest, Inc., the consumer reporting agency and background screening provider, at (800) 445-8001 if I am unable to view my report at iReviewNow.com or have any questions about my report.

3.       I agree and understand that iReviewNow, LLC is a software provider and is neither an employer nor a consumer reporting agency as defined by the Fair Credit Reporting Act. I understand that iReviewNow, LLC is solely providing software through which I may electronically access my report. I understand that the consumer reporting agency who prepared my report is SecurTest, Inc. I understand that iReviewNow nor the consumer reporting agency who procured my report, do not make any employment or other decisions for the Company receiving my report, and the employer is solely responsible for all employment decisions.

4.       By consenting to use iReviewNow, I authorize all legal notices to be provided to me electronically through iReviewNow.com, the email address I have provided understanding that standard text messaging rates apply, as I will receive text messages alerting me to go to iReviewNow.com when my report or notices are ready for my review.

5.       I understand that if I do not view and confirm or dispute my report within five business days from the first text, email message or notice that my report is completed and ready for my review, the Company authorized to review my report may consider a decision based on the contents of my consumer report.

6.       I agree to go to iReviewNow.com to register for automated notification of my report or to view the report when notified.

7.       I have had an opportunity to read or review the Summary of My Rights Under the FCRA and other state notices, other applicable regulations, state and federal laws and consult with legal counsel.

8.      ELECTRONIC SIGNATURE AUTHORIZATION: I hereby certify that if I elect to sign electronically that it may be used by the requesting agency, iReviewNow®, SecurTest®, Inc., and court researchers, investigators, or government entities to rely on it as if it were my original handwritten signature.
INVESTIGATIVE CONSUMER AGENCY CONDUCTING INVESTIGATION, unless noted herein:

SecurTest, Inc.

600 Grand Panama Blvd. Ste. 202

Panama City Beach, FL 32407

(800) 445-8001 | www.securtest.com

iReviewNow® – © 2005-2023 – Patented Intellectual Property of Steven C. Millwee and SecurTest, Inc. - ALL RIGHTS RESERVED

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All of the notices required by law are found at SecurTestNotices.pdf. A copy of these notices are attached to the email transmitted to you when you click Submit.
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Consumer Authorization Form

Notice to those candidates located within the European Union

Please Carefully Complete the Following

Below are 4 background screening options.

Package 1. USA-Based FBI Criminal Background Screening ONLY

Package 2. USA-Based FBI Criminal Background Screening AND International Screening

Package 3. International Screening ONLY

Package 4. International Screening AND US-Based Commercial Screening for International Candidates

Please Carefully Complete the Following

Contact Information

A Summary of Your Rights Under the Fair Credit Reporting Act

FAIR CREDIT REPORTING ACT NOTICE

California Disclosure Regarding Employment Background Report

NEW YORK DISCLOSURE AND RELEASE

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