Background Check Form

Name*

First NameMiddle NameLast Name

Other Known Name or Other Names used

First NameMiddle NameLast Name

Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County*

Primary Phone number*

Please enter a valid phone number.

Email*

example@example.com

Birth date*

Date

Social Security Number*

Drivers License Number*

State*

APPLICANT DISCLOSURE

The Church of the Brethren may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living, which can involve personal interviews with sources such as your neighbors, friends, or associates.

These reports may contain information regarding your credit history, criminal history, social security verification, motorvehicle records “driving records”, workers compensation injuries, employment and/or education history, or other background checks.

Please be advised that the nature and scope of this notice and authorization is all-encompassing to include National Background Investigations, Inc, PO Box 966, Stevensville, MD 21666, 800-798-0079 or another outside organization.

By signing this notice and authorization you are allowing The Church of the Brethren to obtain from any outside organization all manners of consumer reports and investigative reports now and throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer reports.

ACKNOWLEDGEMENT AND AUTHORIZATION

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by The Church of the Brethren
at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance to furnish any and all background information requested by National Background Investigation, Inc, PO Box 966, Stevensville, MD 21666, 800-798-0079 another
outside organization acting on behalf of NATIONAL BACKGROUND INVESTIGATIONS, INC itself. I agree that facsimile (fax), electronic or photographic copy of this Authorization shall be as valid as the original.

New York applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by National Background Investigations, Inc. by contacting the consumer reporting agency identified above
directly.

Maine, Massachusetts, Minnesota, New Jersey and Oklahoma applicants or employees only:Please initial if you would like to receive a copy of a consumer report if one is obtained by National Background Investigations, Inc.

Initials

California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW.Please initial here if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by National Background Investigations, Inc. whenever you have the right to receive such a copy under California law.

Initials

Plese print your name

Signature Signature

Background information