Panel Registration and Payment

Panel Background Check
As part of the Panel Background Check program, your name, appraiser license number, 0R THE STATE WHERE YOU WILL APPLY FOR THE LICENSE, and the status of your background check will be transmitted to Wells Fargo Real Estate Valuation Services (hereafter "Wells Fargo RVS"). Your personal identifiers (e.g. Social Security Number) and the full results of your Panel Background Check (e.g. specific criminal convictions) will NOT be sent to Wells Fargo RVS.

SecurTest does not perform a credit check as part of the Panel Background Check.
Date

MonthDayYear
Date
I have read the above disclaimer and authorize SecurTest, Inc. and/or iReviewNow, LLC. to share the indicated information with Wells Fargo RVS.*

I Agree
Name*

First NameLast Name
E-mail*
Due to the sensitive nature of the information involved, please provide an email address accessible ONLY to yourself.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

WELLS FARGO has requested that you obtain a background report, also known as a consumer background report from SecurTest, Inc., a third-party consumer reporting agency. Pursuant to the Fair Credit Reporting Act, this report may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding your criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment history, or other background checks.

For the purpose of this disclosure, SecurTest does not check your credit or driving record.

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.
Signature - Disclosure

Clear

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.
Full Name*

First NameMiddle NameLast NameSuffix
Have you ever gone by any other name? (i.e. Maiden Name)*

YesNo
First Alias Name

First NameMiddle NameLast Name
Have you ever gone by any other name? (i.e. Maiden Name)*

YesNo
Second Alias Name

First NameMiddle NameLast Name
Have you ever gone by any other name? (i.e. Maiden Name)*

YesNo
Third Alias Name

First NameMiddle NameLast Name
Have you ever gone by any other name? (i.e. Maiden Name)*

YesNo
Fourth Alias Name

First NameMiddle NameLast Name
Your Date of Birth*

MonthDayYear
Your Full Social Security Number*
Numbers only. No dashes

California Disclosure Regarding Employment Background Report - NOTICE REGARDING BACKGROUND CHECKS PER CALIFORNIA LAW

Client/Employer or User identified on page 1 (“Company”) intends to obtain information about you for employment screening purposes from a consumer reporting agency. Thus, you can expect to be the subject of “investigative consumer reports” and/or “consumer credit reports” obtained for employment purposes. Such reports may include information about your character, general reputation, personal characteristics and mode of living. With respect to any investigative consumer report from an investigative consumer reporting agency (“ICRA”), the Company may investigate the information contained in your employment application and other background information about you, including but not limited to obtaining a criminal record report, verifying references, work history, your social security number, your educational achievements, licensure, and certifications, your driving record, and other information about you, and interviewing people who are knowledgeable about you. The results of this report may be used as a factor in making employment decisions. The source of any investigative consumer report (as that term is defined under California law) will be SecurTest, Inc., 600 Grand Panama Blvd, Suite 202, Panama City Beach, FL 32407; tel. # 800.445.8001; www.securtest.com. The Company agrees to provide you with a copy of an investigative consumer report when required to do so under California law.

Under California Civil Code section 1786.22, you are entitled to find out what is in the Investigative Consumer Reporting Agency’s (ICRA) file on you with proper identification, as follows:

In person, by visual inspection of your file during normal business hours and on reasonable notice. You also may request a copy of the information in person. The ICRA may not charge you more than the actual copying costs for providing you with a copy of your file.

A summary of all information contained in the ICRA’s file on you that is required to be provided by the California Civil Code will be provided to you via telephone, if you have made a written request, with proper identification, for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to you.

By requesting a copy be sent to a specified addressee by certified mail. ICRAs complying with requests for certified mailings shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the ICRAs.

“Proper Identification” includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. Only if you cannot identify yourself with such information may the ICRA require additional information concerning your employment and personal or family history in order to verify your identity.

The ICRA will provide trained personnel to explain any information furnished to you and will provide a written explanation of any coded information contained in files maintained on you. This written explanation will be provided whenever a file is provided to you for visual inspection. You may be accompanied by one other person of your choosing, who must furnish reasonable identification. An ICRA may require you to furnish a written statement granting permission to the ICRA to discuss your file in such person’s presence.

Please check this box 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 the Company whenever you have a right to receive such a copy under California law.
Signature - California

Clear

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 o cial records. Final verication of an individual’s identity and proper use of report contents are your responsibility, as Wells Fargo is not the employer and you are the employer as the independ contractor to Wells Fargo. SecurTest, Inc.’s policy requires purchasers of these reports to have signed a Service Agreement. This assures SecurTest, Inc., providers of offcial 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 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. I will receive a copy of my report by SecurTest as well.
Signature - FCRA Notice

Clear

Do you currently live or reside in the State of Georgia OR have you ever lived in the State of Georgia? ANSWER ONE OF THE THREE OPTIONS*

YesNoI have been convicted of a crime in Georgia

Georgia Name-Based Criminal History Record Information (CHRI) Consent/Inquiry Form
Full Name*

First NameMiddle NameLast NameSuffix
Maiden / Alias

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB*

MonthDayYear
Date
Social Security Number*
Georgia requests your Race and Sex (Gender) to perform a more accurate and complete Criminal History Search. Your answers will not be used in the employment process or be shared with the employer or other parties by SecurTest.
Race
Sex / Gender
I hereby authorize SecurTest, Inc. and PSI Background Screening to conduct an inquiry for the purpose of Employment and receive any Georgia and/or national CHRI as authorized by state and federal law.

This authorization is valid for 90 days from date of my signature.

I do not give consent to the above-named entity to perform periodic criminal history background checks for the duration of my employment.

Purpose Code Used (check one): Note: Only one inquiry may be performed per consent form.

NON-CRIMINAL JUSTICE PURPOSES
E = Employment
Date

MonthDayYear
Date
Signature - GA*

Clear

Additionally, we are required to obtain information on your Appraiser, Real Estate Broker, or other applicable professional License, including State of Issuance and License Number. Please enter the required information in the space provided below.

Please Note: Where you are unsure which license to put below, refer to the Service Agreement Letter provided to you by Wells Fargo RVS. This documentation should specify which license should be given to the Background Screening Provider.

Any discrepency between the information below and Wells Fargo RVS's records may delay their receipt of your results.
Appraiser License State OR the State Where You Will Apply for the License*
Appraiser License Number if one has been issued to you

For the Panel Background Screening Program, we require that you pay securely online using a Visa, MasterCard, or Discover. We do not accept American Express for Panel orders.*

I understand and agree

Payment*

Panel Background Check$29.00

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

Payment will not be submitted until you click "Submit Payment and Proceed"

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 ★ or by going to www.securtest.com
DO NOT CLOSE THE WINDOW AFTER CLICKING SUBMIT, AS IT TAKES SEVERAL MINUTES FOR THE FORM TO PROCESS.*

I UNDERSTAND
CCEmail
Should be Empty:

Panel Background Check

Georgia Name-Based Criminal History Record Information (CHRI) Consent/Inquiry Form