QSI-2 Current QSI Employee - Non-USA Passport Holder

• You have never been issued a USA passport.

• You must be a current QSI employee.

• You will be provided with FASTscreen® questions.

• Except for countries QSI schools are located and your passport country, SecurTest will perform International Background Checks in other countries you resided over the last 10 years.

• SecurTest will check Foreign and USA Watchlists. As part of your application, SecurTest, Inc. will conduct your background check. Please read the following notices and authorizations.

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 scroll down, and press "Next."

The website and form are confidential and secure. You can be confident that your personal identifiers are protected and encrypted.
This authorization is required for us to complete your background check for Quality Schools International (hereafter "QSI"). 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 iReviewNow, SecurTest, Inc., and/or court researchers, investigators, or government entities to verify your authorization for your background check. You hereby give consent for SecurTest, Inc. to periodically re-check your background report without further notice or consent.

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 encrypted and secure.
I understand and agree*

In the space below, please list the payment code provided to you by QSI.*
Please verify and re-enter the payment code below*

First Name*
Last Name*
Middle Name (if any)
Full Maiden Name (if any; first, middle, and last)
Suffix/Prefix (if any)

Have you ever used any other Name(s), including married names?*

YesNo
Please list any other Name(s) Used. If you have used multiple names, please separate each name by pressing Enter.
Select the QSI location or Country at which you are employed.*

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.
Your Birth Date*

MonthDayYear
Government Identification Number, if you have been issued such.
What country or entity issued the Identification
Your father's full name, including First, Middle and Last*
Your mother's full maiden name, including First, Middle and Last*
Your Passport Number*
Country Passport Issued*

1. Country of current residence*
Current Residence Address (Not a PO Box), including country*
1D. Dates you have lived at your current address (mm/yy to mm/yy or mm/yy to current)
1M. Number of months you have lived at your current address.
Mailing Address, if different than above, including country
Have you lived in any other foreign country (non-USA) not already listed where you were 18 or older and lived there 9 months or more?*

YesNo

2. Name of Next Foreign Country you resided*
2nd Foreign (non-USA) country address, including country, if not listed above where you were 18 or older and lived there 9 months or more.*
2A. Dates you lived in this country (example mm/yyyy to mm/yyyy)
2B. How many months did you live in this country?
3. Have you resided in another foreign country in the past 10 years and were 18 or older and lived there 9 months or more?*

YesNo

3. Name of Country*
3rd Foreign (non-USA) country address, including country.*
3A. Dates you lived in this country (example mm/yyyy to mm/yyyy)*
3B. How many months have you live in this country?*
4. Have you resided in another foreign country in the past 10 years where you were 18 or older and lived there 9 months or more?*

YesNo

4. Name of Country*
4th Foreign (non-USA) country address, including country*
4A. Dates you lived in this country (example mm/yyyy to mm/yyyy)*
4B. How many months did you live in this country?*
5. Have you resided in another foreign country in the past 10 years where you were 18 or older and lived there 9 months or morer?*

YesNo

5. Name of Country*
5th Foreign (non-USA) country address, including country*
5A. Dates you lived in this country (example mm/yyyy to mm/yyyy)*
5B. How many months did you live in this country?*

Email Address*
Your Cell Phone or Contact Number*

Area CodePhone Number
Your cell phone provider:
ex: Sprint, AT&T, T-Mobile, etc
Alternate Phone Number

Area CodePhone Number

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

QSI International identified on the first page (“the Client” or "QSI) requires a background report be obtained for your employment, continued employment or placement. No credit report will be obtained as part of this background investigation.

These background screening 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 to the extent permitted by law.
Signature

Clear

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 Quality Schools International (QSI) without further consent by me. I understand that I will be responsible for uploading my full report to QSI once I receive the report from SecurTest and have completed iReviewNow.*

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 to Quality Schools International, its member schools, assigns, or affiliates (hereafter "QSI") following my receipt, review and approval of my completed Report via iReviewNow. Moreover, upon my approval via iReviewNow, I authorize QSI to transmit my report as may be required by various schools or potential employers seeking this information to make placement and/or hiring decision. I release and forever hold harmless QSI, SecurTest, Inc. and iReviewNow, LLC for releasing any or all of my background report or reports and my iReviewNow responses. QSI does not make hiring decisions or recommendations except for schools it manages or owns. All other employment or placement decisions are solely the responsibility of the employer. I also understand that if I do not review my Report via completion of the iReviewNow questionnaire, my report will not be transmitted to QSI.
I Agree*

I understand and agree to the statement above.

iReviewNow - Ensuring Accuracy and Fairness

INSTANT ABILITY TO REVIEW YOUR REPORT. Quality Schools International (hereafter "QSI") uses the exclusive patented iReviewNow software, which allows you to review your background (consumer) report to ensure that it is accurate.

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:

SecurTest, Inc. * 600 Grand Panama Blvd. Ste 202 * Panama City Beach, FL 32407 * (800) 445-8001 | www.securtest.com

iReviewNow® – © 2005-2019 – Patented Intellectual Property of Steven C. Millwee and SecurTest, Inc. - ALL RIGHTS RESERVED
Signature - Use Your Mouse to Sign in the Box*

Clear
Signature /s/*
Type your full legal name as your electronic signature.
Today's Date

MonthDayYear

QSI Questionnaire
Answering “yes” to any of the following questions does not constitute an automatic bar to employment or placement. Factors such as date of the offense, seriousness and nature of the violation or matter, rehabilitation and position applied for will be considered. We are looking for reliable factual information. When answering the next set of questions, be sure to give accurate and truthful answers. If we discover that you have given inaccurate information or have lied, your contract with QSI may be in jeopardy. You must provide a detailed description to explain your answers where required.

We are aware there is no such thing as a PERFECT PERSON. We are looking for reliable factual information. When answering the next 10 questions, be sure to give accurate and truthful answers. If we discover that you have given inaccurate information or lied, you will not be hired or placed. Most of us have done something in our lives of which we are not very proud.

1. Has your professional license, certificate, permit, credential, endorsement, or registration ever been disciplined, suspended, revoked, reprimanded, restricted, curtailed or voluntarily surrendered?*

YesNoI'm not sure

1.A. You answered that your professional license, certificate, permit, credential, endorsement, or registration has been disciplined, suspended, revoked, reprimanded, restricted, curtailed or voluntarily surrendered. Explain in detail. Provides dates, locations, agencies, complaint details, and action taken.*

2. Do you have any pending complaints before any regulatory board or agency? .*

YesNoI'm not sure

2.A. You answered that you pending complaints before a regulatory board or agency. Explain in detail. *

3. Is there any investigation or adverse action now pending against you?*

YesNoI'm not sure

3.A. You answered there is a pending investigation or adverse action pending against you. Explain in detail. *

4. Have you ever been charged with, convicted or entered a plea, including a plea of nolo contendere (no contest or Alford plea), to any felony or misdemeanor whether or not sentence was imposed or suspended, except minor traffic violations? (We check your criminal history. Providing false or misleading information will result in denial of employment or placement as a teacher or loss of your position of retained.)*

YesNoI'm not sure

4.A. You answered that you been charged with, convicted or entered a plea, including a plea of nolo contendere (no contest or Alford plea), to a felony or misdemeanor whether or not sentence was imposed or suspended, except minor traffic violations. Explain in detail. Provide dates, locations (city, state country), law enforcement agency names, charges, and what happened in court.*

5. Have you ever resigned, been restricted, disciplined, or discharged from any position, including the armed forces, while under suspicion of having engaged in criminal, immoral, unethical behavior or unprofessional conduct?*

YesNoI'm not sure

5.A. You answered that you resigned, been restricted, disciplined, or discharged from any position, including the armed forces, while under suspicion of having engaged in criminal, immoral, unethical behavior or unprofessional conduct.Explain in detail, including the dates and what happened. *

6. Are you under investigation for of having engaged in criminal, immoral, unethical behavior or unprofessional conduct?*

YesNoI'm not sure

6.A. You answered that you are under investigation for of having engaged in criminal, immoral, unethical behavior or unprofessional conduct. Explain in detail, including the the dates, location (city, state) and what happened. *

7. Have you ever been denied a professional license, certificate, permit, credential, endorsement, or registration?*

YesNoI'm not sure

7.A. You answered that you have you been denied a professional license, certificate, permit, credential, endorsement, or registration. Explain in detail. *

8. Have you ever been the subject of a child protective order or investigation?*

YesNoI'm not sure

8A. You answered that you have you been the subject of a child protective order or investigation. Explain in detail, including the dates, and what happened. *

9. Have you ever been the subject of a temporary or permanent restraining order where you were requiring to stay away from a person or person or location?*

YesNoI'm not sure

9A. You answered that you have you been the subject of a temporary or permanent restraining order where you were required to stay away from a person or location.Explain in detail, including the dates, location (city, state) and what happened. *

10. When we search your social media post/profiles and do a search engine (Google) key word name search will we find any inappropriate pictures, culturally insensitive comments/posts, public comments that you made or forwarded that are not appropriate for professional educators to be posting on the internet?*

YesNoI'm not sure

10A. You answered that a search your social media post/profiles we find inappropriate pictures, culturally insensitive comments/posts, public comments you made or forwarded that are not appropriate for professional educators. Explain in detail, including, the dates, what was posted, where it was posted, the reason for the post, and the dates of the post. *

11. When we search your social media posts and profiles, will we find any information that shows you are attracted to children, been accused of molesting a child or children, or been forced to resign a position over such allegations of sexual misconduct?*

YesNoI'm not sure

11.A You answered that when a search of your social media posts and profiles, it will information information that shows you are attracted to children, been accused of molesting a child or children, or been forced to resign a position over such allegations of sexual misconduct. Explain in detail, including the dates, locations, and what happened and what will be found.*

12. There is information on the Internet, reports, or records that claims I have been romantically or sexually involved with students or children under the age of 18.*

YesNoI'm not sure

12A. You answered there is information on the Internet, reports, or records that claims you have been romantically or sexually involved with students or children under the age of 18. Explain in detail, including dates and circumstances. *

13. Has any disciplinary action been taken against you due to behaviors that would not permit you to work in a school with teenagers and children such as, but not limited to, illegal or prescription drug abuse, alcohol use, sexual misconduct, being arrested or any other improper behavior?*

YesNoI'm not sure

13A. You answered that disciplinary action has been taken against you due to behaviors that would not permit you to work in a school with teenagers and children such as, but not limited to, illegal or prescription drug abuse, alcohol use, sexual misconduct, being arrested or any other improper behavior. Explain in detail, including the dates, the source of the information, and what happened. *

14. The background investigation will find that I have been accused of having sexual contact with a minor.*

YesNoI'm not sure

14A. You answered that the background investigation will find that you have been accused of having sexual contact with a minor. Explain in detail, including the dates, when, where, what was the allegation, and outcome. *

Notice to those candidates located within the European Union or Switzerland

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.

· In order to facilitate access to my background report by myself, Search Associates, and any individual school I select, SecurTest, Inc. will maintain my personal information on file as listed on this release and my completed background report for 3 years from the date I complete this release.

· Privacy Shield- https://www.privacyshield.gov/welcome

· Privacy Shield Certificate- https://www.privacyshield.gov/participant?id=a2zt0000000GpNdAAK&status=Active

· SecurTest Privacy Policy- https://securtest.com/2012/privacy_policy.php

By clicking submit I agree to all terms and conditions set forth herein.

I certify under penalty of perjury that my answers to questions were truthful.

My electronic signature shall be the same as a handwritten signature, and shall be used as evidence that each form as required by law as been received and reviewed by me, as I reviewed each form when completing this request. I further acknowledge that all legal notices required by law or regulations were provided to me, which can be reviewed at https://www.securtest.com/SecurTestNotices.pdf and are an official part of my consent and authorization for SecurTest and the Employer, Entity, or User to perform the background investigaiton. These notices and forms were on stand-a-lone screens or pages as seen the PDF version referenced herein.

DO NOT CLOSE THIS WINDOWN AFTER CLICKING SUBMIT UNTIL THE THANK YOU PAGE APPEARS, AS IT MAY TAKE A MINUTE OR TWO TO UPLOAD YOUR INFORMATION.
Signature

Clear
CC email address*
PLEASE BE PATIENT.....DO NOT CLOSE THIS WINDOW OR GO TO ANOTHER APPLICATION AFTER CLICKING SUBMIT UNTIL THE THANK YOU PAGE APPEARS, AS IT MAY TAKE A MINUTE OR TWO TO UPLOAD YOUR INFORMATION.
Should be Empty: