Background Check Consent Form

BACKGROUND CHECK CONSENT FORM

This Background Check Consent Form (the "Agreement") is entered into by and between Company Name: (the "Company") and Applicant Name: for the purpose of evaluating the Applicant for employment or continued employment in the position of on Application Date: .

RECITALS

WHEREAS, the Company seeks to verify information provided by the Applicant and to obtain background information relevant to the Applicant's suitability for the position described above;

WHEREAS, the Applicant desires to be considered for employment and acknowledges that the Company may obtain consumer reports, investigative consumer reports, and other reports for employment screening purposes;

WHEREAS, the parties desire to set forth the Applicant's consent and the terms under which such reports may be obtained, reviewed, retained and used.

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

1. AUTHORIZATION

The Applicant hereby authorizes the Company, its agents, representatives, and any consumer reporting agency retained by the Company to obtain and prepare consumer reports or investigative consumer reports concerning the Applicant for employment purposes. The Applicant authorizes current and former employers, educational institutions, law enforcement agencies, courts, motor vehicle departments, and other persons or entities to provide information about the Applicant to the Company or its agent.

2. INFORMATION PROVIDED BY APPLICANT

3. SCOPE OF AUTHORIZATION

The scope of the background check may include one or more of the following categories. The Applicant authorizes the Company to obtain each category checked below:

4. NOTICE OF RIGHTS AND REPORT USE

The Applicant understands that a consumer report or investigative consumer report may be obtained for employment purposes. The Applicant has the right to request disclosure of the nature and scope of any investigative consumer report, if one is requested. If the Company contemplates taking adverse action based in whole or in part on information contained in such a report, the Applicant will be provided with a copy of the report and a written description of the Applicant's rights under applicable law prior to final adverse action.

5. DISCLOSURE, RELEASE AND INDEMNIFICATION

The Applicant hereby releases and holds harmless the Company, its officers, directors, employees, agents, and any third-party consumer reporting agencies and information providers from any and all claims, liabilities, or damages arising from the collection, preparation or disclosure of any consumer report or investigative consumer report, except to the extent such claim arises from the Company's willful misconduct or violation of applicable law. The Applicant also authorizes the Company to share the results of any reports with employees, representatives, or agents of the Company for the purpose of making employment decisions.

6. CONFIDENTIALITY AND RETENTION

Information obtained under this Agreement will be treated as confidential and retained in accordance with the Company’s records retention policies and applicable law. Access to reports will be limited to personnel with a business need to know. The Company will take reasonable measures to safeguard report information.

7. DURATION AND REVOCATION

This authorization is valid for one year from the date of the Applicant’s signature below unless revoked earlier in writing. The Applicant may revoke this authorization in writing; however, revocation will not affect any action taken in reliance upon this authorization prior to receipt of the revocation.

8. ADVERSE ACTION PROCEDURES

If an adverse employment action is taken based in whole or in part upon information obtained in a consumer report, the Company will provide the Applicant with a pre-adverse action notice containing a copy of the report and a summary of rights, and after final determination, a final adverse action notice describing the action taken and the reporting source that furnished the information.

9. NOTICES

10. MISCELLANEOUS PROVISIONS

Governing Law: This Agreement will be governed by and construed in accordance with the laws of the state in which the Company’s principal place of business is located, without regard to conflict of law principles.

Entire Agreement: This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements and understandings, whether written or oral.

Severability: If any provision of this Agreement is held to be invalid or unenforceable, the remaining provisions will remain in full force and effect.

Amendments; Waiver: No amendment or waiver of any provision of this Agreement will be effective unless in writing and signed by both parties. No failure or delay by either party in exercising any right will operate as a waiver of that right.

Counterparts: This Agreement may be executed in counterparts, each of which will be deemed an original and all of which together will constitute one and the same instrument.

11. ACKNOWLEDGMENTS

By signing below, the Applicant certifies that the information provided in this form is true and correct to the best of the Applicant’s knowledge, expressly consents to the release of the information identified herein, and acknowledges receipt of a clear disclosure that a consumer report and/or investigative consumer report may be obtained for employment purposes.

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