Background Check Agreement Form

BACKGROUND CHECK AGREEMENT

This Background Check Agreement (the Agreement) is entered into as of by and between Client Name: , with principal address: (Client), and Applicant Name: , with address: (Applicant).

RECITALS

WHEREAS, Client requires a background investigation of Applicant for the purpose of assessing Applicant's suitability for employment, engagement, licensure, or volunteer service described herein; and

WHEREAS, Applicant acknowledges receipt of a disclosure and authorizes Client and its designated agents to obtain and use consumer reports, investigative consumer reports, and other background information about Applicant for the Permitted Purpose set forth below; and

WHEREAS, Client and Applicant desire to set forth the terms and conditions under which such background information will be requested, used, stored and disclosed.

NOW, THEREFORE, in consideration of the mutual covenants and promises contained herein, the parties agree as follows:

1. AUTHORIZATION AND CONSENT

Applicant expressly authorizes Client and its authorized agents to obtain background information about Applicant, including consumer reports and investigative consumer reports, for the purpose of evaluating Applicant's suitability for the position, contract, licensure, or volunteer capacity identified by Client. Applicant authorizes the disclosure of any relevant records and information by third parties, including but not limited to employers, educational institutions, courts, law enforcement agencies, licensing agencies, and credit reporting agencies.

Applicant printed name for authorization:   Date of birth:   Last 4 of SSN:

2. SCOPE OF INVESTIGATION

Client may procure any of the following checks as applicable to the Permitted Purpose. Applicant acknowledges and consents to the types of checks selected below:

Selected Checks: Criminal Records Sex Offender Registry Motor Vehicle/Driving Record Employment Verification Education Verification Credit History (if permitted) Professional Licenses Other:

3. PERMITTED PURPOSE

The parties agree that the Permitted Purpose for obtaining the reports described in this Agreement is: . Client will use the information only for the stated Permitted Purpose and as required by applicable law.

4. BACKGROUND CHECK REPORTS; ADVERSE ACTION

If Client receives a background check report that may adversely affect Applicant's eligibility for the position, Client will comply with any pre-adverse action procedures required by law prior to making a final adverse determination. Applicant shall be provided an opportunity to review and respond to the information in the report prior to final action being taken, consistent with applicable legal requirements.

5. USE, STORAGE, AND DISCLOSURE OF INFORMATION

Client will treat all background check information as confidential and will limit access to personnel who have a legitimate need to know for the Permitted Purpose. Client may retain copies of reports for its records for a reasonable retention period necessary to comply with recordkeeping obligations and defend against claims. Client will not disclose background check reports except to: (a) the Applicant where required by law; (b) Client's representatives and advisors who have a need to know; or (c) as otherwise required by law.

6. APPLICANT REPRESENTATIONS AND WARRANTIES

Applicant represents and warrants that all information provided to Client in connection with this Agreement is true, accurate and complete. Applicant authorizes Client to verify and investigate any statements made by Applicant and agrees to provide additional information reasonably requested to complete the background check process.

7. CONFIDENTIALITY AND DATA SECURITY

Client will implement administrative, technical and physical safeguards designed to protect the confidentiality and integrity of Applicant information consistent with industry standards and applicable law. In the event of an unauthorized disclosure of personal information, Client will take reasonable steps to investigate and, where required by law, notify Applicant and relevant authorities.

8. INDEMNIFICATION

Applicant agrees to indemnify and hold Client and its agents harmless from any claims, losses, costs or liabilities arising from Applicant's intentional misrepresentation, omission of material facts, or unauthorized use of the background information obtained under this Agreement. Client agrees to indemnify Applicant for any willful misuse of Applicant's information by Client in violation of this Agreement.

9. NOTICES

All notices required or permitted under this Agreement shall be in writing and delivered to the addresses set forth below or such other address as a party may designate by written notice in accordance with this section.

10. AMENDMENTS; WAIVER

No modification, amendment, or waiver of any provision of this Agreement shall be effective unless in writing and executed by both parties. Failure to exercise any right shall not constitute a waiver of that right unless a written waiver is executed by the party entitled to the right.

11. GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the state of , without regard to conflict of law principles. The parties submit to the exclusive jurisdiction of the courts located in that state for disputes arising under this Agreement, to the extent permitted by law.

12. ENTIRE AGREEMENT; SEVERABILITY

This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior oral and written agreements and understandings. If any provision of this Agreement is determined to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

13. COUNTERPARTS

This Agreement may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one and the same instrument. Signatures delivered electronically or by facsimile shall be deemed originals for all purposes.

14. MISCELLANEOUS PROVISIONS

If Applicant withdraws consent or contests the accuracy of any information, Applicant must notify Client in writing at the Applicant Notice Address above. Client shall consider any additional information provided by Applicant prior to taking final action and shall document the consideration of such information.

APPLICANT ACKNOWLEDGEMENT

By signing below, Applicant acknowledges that Applicant has read and understands this Agreement, that Client has provided Applicant with a clear written disclosure that a consumer report or investigative consumer report may be obtained, and that Applicant voluntarily consents to the background checks authorized herein.

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