Microsoft Word - CONSUMER REPORT DISCLOSURE

FCRA DiscRelEmp T 12/03

CONSUMER REPORT DISCLOSURE & RELEASE

(EMPLOYMENT)

DISCLOSURE

In connection with your employment or application for employment (including contract for services), consumer reports may be

requested from USIS Commercial Services (“USIS”). These reports may include the following types of information: names and

dates of previous employers, reason for termination of employment, work experience, accidents, academic history, professional

credentials, and drugs/alcohol use. Such reports may contain public record information concerning your driving record, workers’

compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which

maintain such records; as well as information from USIS concerning previous driving record requests made by others from such

state agencies and state provided driving records.

You have the right to make a request to USIS, upon proper identification, to request the nature and substance of all information in

its files on you at the time of your request, including the sources of information and the recipients of any reports on you that

USIS has previously furnished within the two-year period preceding your request. USIS may be contacted by mail at P. O. Box

33181, Tulsa, Oklahoma, 74153, or by phone at (800) 381-0645.

 Oklahoma Applicants Only: I request a copy of any credit report requested on me.

 Minnesota Applicants Only: I request a copy of any consumer report requested on me.

RELEASE

I AUTHORIZE, WITHOUT RESERVATION, USIS, AND ANY PARTY OR AGENCY CONTACTED BY USIS, TO

FURNISH THE ABOVE-MENTIONED INFORMATION.

USIS is authorized to disclose all information obtained to the requesting entity for the purpose of making a determination as to

my eligibility for employment, promotion or any other lawful purpose. I agree that such information which USIS has or obtains,

and my employment history if I am hired, may be supplied by USIS to other companies that subscribe to USIS. If hired or

contracted, this authorization shall remain on file and shall serve as ongoing authorization for the procurement of consumer

reports at any time during my employment or contract period.

By signing below, I certify that I have read and fully understand this release, that prior to signing I was given an opportunity to

ask questions and to have those questions answered to my satisfaction, and that I executed this release voluntarily and with the

knowledge that the information being released could affect my being hired, my employment, or my eligibility for promotion.

_______________________________________________ ________________________________________________

Print Applicant Name Applicant Signature

__________________________________________ __________________________________________

Social Security Number Date

Notice to California Applicants

Under California law, the consumer reports we order on you for employment purposes within the State of California are

defined as investigative consumer reports. These reports may contain information on your character, general reputation,

personal characteristics and mode of living.

Under section 1786.22 of the California Civil Code, you may view the file maintained on you by USIS during normal business

hours. You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication

services, by appearing at USIS in person, by mail, or by telephone. The agency is required to have personnel available to

explain your file to you and the agency must explain to you any coded information appearing in your file. If you appear in

person, a person of your choice may accompany you, provided that this person furnishes proper identification.

I request to receive a free copy of any investigative consumer report ordered on me by checking this box.

(California applicants only)