DISCLOSURE AND AUTHORIZATION FORM

TO OBTAIN CONSUMER REPORTS FOR EMPLOYMENT PURPOSES

 

 

Please Read Carefully Before Signing the Authorization


Return to Apply for Positions

 

 

DISCLOSURE

 

In considering you for employment and, if you are employed, in considering you for subsequent promotion, assignment, reassignment, retention, or discipline, Valeo Behavioral Health Care may request and rely upon one or more consumer reports or investigative consumer reports about you that we obtain from a consumer reporting agency, such as IntelliCorp Records, Inc.

 

For explanation purposes:

  • a "consumer report" is a written, oral or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in making an employment-related decision about you.  Such information may include, for example, credit information, criminal history reports, or driving records; and

  • an "investigative consumer report" is a consumer report in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your prior employers, neighbors, friends, or associates, or with others who may have knowledge concerning any such items of information.  In the event an investigative consumer report is requested about you, you are entitled to additional disclosures regarding the nature and scope of the investigation requested, as well as a written summary of your rights under the Fair Credit Reporting Act ("FCRA").

 

 

Under the FCRA, before the Company can obtain a consumer report or investigative consumer report about you for employment purposes, we must have your written authorization.  Before we take adverse action on the basis, in whole or in part, of information in that report, you will be provided a copy of that report, the name, address, and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA.


AUTHORIZATION

 

I have read and understand the foregoing Disclosure, and authorize the Company to obtain and rely upon consumer reports or investigative consumer reports in considering me for employment and, if I am employed, in considering me for subsequent promotion, assignment, reassignment, retention, or discipline. By my signature below, I authorize the Company to obtain any such reports and to share the information received with any person involved in the employment decision about me.

 

 

I also agree that this Disclosure and Authorization in original, faxed, photocopied, or electronic (including electronically signed) form will be valid for any consumer reports or investigative consumer reports that may be requested about me by or on behalf of the Company.                                                                                                                           

 

 

 


Personal Data

 

 

Last Name First Name Middle Name

 

Current Address


  


Dates Lived Here

 

Addresses for the Past Seven Years: (include street, city, state, zip code)Dates of Residence:


Date of Birth Other Names Used (including maiden name) Years Used
Driver's License #  License State SSN


Email address (may be used for official correspondence)      

 

I have the right to make a request to IntelliCorp Records, Inc, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including sources of information, and the recipients of any reports on me which IntelliCorp Records, Inc has previously furnished within the two year period preceding my request.  

 

I certify that all elements of the personal data I have provided are true, accurate and complete. I understand and agree that any omission, false statement, misleading statement, or answer made by me on my application or any supplements to it and in any interviews will be sufficient grounds for rejection of employment and my discharge after employment.



Printed Name Applicant Signature Date


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