Microsoft Word - Consent Form.Rev.1.19.05

CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK IN
COMPLIANCE WITH THE FCRA

CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK IN

COMPLIANCE WITH THE FCRA

(FAIR CREDIT REPORTING ACT)

Date:_____________

Driver Lic.# (if checking driving

record)

__________________________

Driver Lic. State ________________

______________________

Last Name

______________________

First Name

_______________________

Middle Initial

_____________________________________________________________________

Maiden and/or Other Last Names Used

______________________

City*

______________________

County*

_______________________

State*

______________________

Date of Birth**

______________________

Social Security Number**

Circle One**:

Male /Female

This authorization and consent for release of personal information acknowledges that

_____________________________________________________ (Hereafter referred to as "Company") and/or its agent,

Trak-1 Technology, may now, or at any time I am assigned to, volunteer with or am employed by this Company, conduct

investigations whether the records are of a public, private or confidential nature. These investigations might include, but

are not limited to, searches of educational institutions attended; state driving records; financial or credit institutions,

including records of loans; records of commercial or retail credit agencies; other financial statements; records of previous

employment, including work history, efficiency ratings, complaints and grievances filed by or against me; records and

recollections of attorney-at-law or of other counsel, whether representing me or any other person (in either a civil or

criminal case in which I have been involved); records from the U.S. Veterans' Administration; criminal history information

of file in local, state or federal agencies; and motor vehicle records, and following an employment offer, workers'

compensation reports from either the Department of Labor, National Personnel Records or the Industrial Commission or

similar agencies under the provisions of the Fair Credit Reporting Act 15, USC section 1681 et seq. I also authorize the

National Personnel Records Center, or other custodian of my military service record, to release to Trak-1 Technology, the

following information and/or copies of documents from my military service record: DD214, service record, and any

disciplinary records.

I understand that these searches will be used to determine work assignment or employment eligibility under the

Company's employment or volunteer policies. Therefore, I authorize and consent for full release of records (either orally

or in writing) to the authorized representatives of the Company. In addition, I release and discharge the Company and its

agent and associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs expenses or

any other charge or complaint filed with any agency arising from retrieving and reporting this information. I understand

that according to the Federal Fair Credit Reporting Act, I am entitled to know whether employment was denied based

upon the information obtained and to receive, upon written request, a disclosure of the background report. I also

understand that I may request a copy of the report from

Trak-1 Technology / PO Box 130159

Houston, Texas 77219

at telephone number

1-800-600-8999

. After reading this document, I fully understand its

contents and authorize the background verification.

Are you applying for employment in California, Minnesota or Oklahoma? Yes ___ No___

If so, do you want a copy of any Consumer Report prepared concerning you? Yes ___ No ___

I understand that California law required Company to give me a copy of any report requested within seven (7) days of the

date the information was obtained and that failure to do so will expose Company to liability (Section 1786.29).

* AS SHOWN ON THE ORIGINAL APPLICATION

** TO BE USED ONLY FOR CRIMINAL HISTORY SEARCHES, AND NOT A PART OF THE PERSONNEL FILE

The following are my responses to questions about my criminal record history (if any) with descriptions to any question with a

YES answer:

1. Have you ever been convicted or plead guilty before a court of any federal, state, or municipal criminal offense? (Excluding

minor traffic violations)

YES

If YES, please provide an explanation below:

________________________________________________________________________________________________________

2. Have you ever received deferred adjudication or similar disposition for any federal, state or municipal criminal offense?

(Excluding minor traffic violations)

YES

If YES, Please provide an explanation below:

________________________________________________________________________________________________________

3. Have you ever received probation or community supervision for any federal, state or municipal criminal offense? YES NO

If YES, Please provide an explanation below:

________________________________________________________________________________________________________

4. Have you ever been arrested for molesting or abusing a minor?

YES

If YES, please provide an explanation below:

________________________________________________________________________________________________________

5. Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States?

YES NO

If YES, Please provide an explanation below:

________________________________________________________________________________________________________

6. As of the date of this authorization, do you have any pending criminal charges against you? YES

If YES, Please provide an explanation below:

________________________________________________________________________________________________________

THIS SECTION IS TO BE USED TO LIST ALL COUNTIES AND STATES OF RESIDENCE SINCE AGE 18 OR HIGH

SCHOOL GRADUATION. YOU MUST BE SPECIFIC ABOUT DATES OF RESIDENCE.

CITY/TOWN

COUNTY

STATE

DATES FROM

I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS AUTHORIZATION IS TRUE, CORRECT AND

COMPLETE. I UNDERSTAND THAT IF ANY INFORMATION PROVES TO BE INCORRECT OR INCOMPLETE THAT

GROUNDS FOR THE CANCELING OF ANY AND ALL OFFERS OF EMPLOYMENT WILL EXIST AND MAY BE USED

AT THE DISCRETION OF ____________________________________________________.

Signed this _________________ day of _________________________________, 20_____

Applicant (Print Name) _________________________________________________________________________

Applicant Signature ___________________________________________________________________________