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Consent Form - Disclosure of Information:
Name:
_____________________________________________________
Social
Security #: ___ - ___ - _____ Home
Phone #: _____________
Driver's License #:
________________________ State
Issued: ______
Name
as it appears on license:
_______________ Date of
Birth ______
Home Address:
______________________________________________
City: ______________________ State:
_______ Zip:
______________
I hereby give consent for an
investigative consumer report to
be done on me for employment or
tenant purposes. I hereby
authorize, without reservation,
any law enforcement agency,
administrator, state agency,
state repository, former
employer, corporation, credit
agency, educational institution,
city, state, federal court,
military institution,
information service bureau,
employer or insurance company
contacted by ___________________
to furnish any and
all information required. I do understand
the investigation will include
information from law enforcement
agencies, state agencies and
public records information, such
as credit, social security,
criminal, motor vehicle and
workers' compensation in
accordance with the American
with Disabilities Act. This
report will include information
as to my character work habits,
performance and experience,
along with the reasons for
termination of past employment
from previous employers. This
releases the aforesaid parties
from any liability and
responsibility for collecting
the above information at any
time.
According to the Fair Credit
Reporting Act (Law 91-508) SS
606:
A person may not procure or
cause to be prepared an
investigative consumer report on
any consumer unless it is
clearly and accurately disclosed
to the consumers that an
investigative consumer report
including information as to his
character, general reputation,
personal characteristics and
mode of living and employment
history, whichever are
applicable, may be made. I also
understand that if I am denied
employment because of the
consumer investigation, it is my
right to have the name of the
agency or agencies disclosed to
me within the time allowed. This
authorization, in original or
copy form, shall be valid for
this and any further reports or
updates that may be requested.
Signed:
__________________________________
Date: ___________
Company Requesting Information:
___________________________________________________________
Please Sign & Fax this form to: QuickCrimeOnline,
Inc. at 303-455-4771
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