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Sample Disclosure/
Authorization

Fair Credit Reporting Act

Disclosure & Authorization Regarding Procurement Of An Investigative Consumer Report

In connection with your application for employment or when deciding whether to modify or continue your employment (if you are hired), we may obtain and use an "investigative consumer report" about you from a "consumer reporting agency." A "consumer reporting agency" is a person or business which, for monetary fees, dues, or on a cooperative nonprofit basis, regularly assembles or evaluates consumer credit information or other information on consumers for the purpose of furnishing "investigative consumer reports" to third parties.

This report may include information as to your character, general reputation, personal characteristics and mode of living. This information may be obtained by contacting your previous employers and/or references supplied by you or others.

In the event that information from the report is utilized in whole or in part in making an adverse decision with regard to your employment, before making the adverse decision, we will provide you with a copy of the investigative consumer report and a description in writing of your rights under the law.

Please be advised that you have the right to request, in writing, within a reasonable time, that we make a complete and accurate disclosure of the nature and scope of the information requested. Such disclosure will be made to you within 5 days of the date on which we receive the request from you or within 5 days of the time the report was first requested.

The Fair Credit Reporting Act gives you specific rights in dealing with consumer reporting agencies. You will be given a summary of these rights together with this document.

By your signature below, you hereby authorize us to obtain a consumer investigative report about you.

     
Applicant's Signature   Date

 
Applicant's Printed Name

 
Applicant's Address

 
City/State/Zip

 
Social Security Number

 

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ODM makes complying with the Fair Credit Report Act simple.
 

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