Fill and Sign the Notice of Employment Action Form

Adverse Employment Action NoticeBasic form © James R. McDade (ver 07-22-05) 209-667-2300 ADVERSE EMPLOYMENT ACTION NOTICE Note: Employers use this form to notify a prospective employee or current employee of the adverse action taken as a result of information disclosed in a consumer report. (Delete this note prior to use.)Date: ________________________Name of Job Applicant or EmployeeAddressCity, State, ZipDear ____________________:Based on information contained in a  credit report  investigation report, the above- identified employer has determined that it will [not hire you for the position you sought] [terminate your employment] .The following entity (formally referred to as a “Consumer Reporting Agency”) provided a report: [Name of Consumer Reporting Agency, Investigator, or Reporting Entity][Address][Phone] The Consumer Reporting Agency did not make the decision to take the employment action described above. Therefore, the Consumer Reporting Agency will be unable to provide to you the specific reasons why this employment action is being taken.Pursuant to federal law and California Civil Code §1785.20, you have the right to request and obtain within 60 days a free copy of the credit report or investigative (background check) report directly from the Reporting Agency identified above, and from any other consumer credit reporting agency that compiles and maintains files on consumers on a nationwide basis. There will be no charge for a copy of the report if your request is made within 60 days of receipt of this Notice of Adverse Employment Action. If your request is made after 60 days, there may be a charge in order to obtain a copy. You were earlier provided a copy of this consumer report on _______________, 200__. You must directly contact the Report Agency above to obtain a copy of the report.You also have a right under federal law and pursuant to California Civil Code §1785.16 and §1786.24 (whichever is applicable) to dispute the accuracy or completeness of any information contained in the report provided by the Reporting Agency. You must directly contact the Reporting Agency as soon as possible to correct any information in the report that you believe is incorrect. Sincerely,[Insert Employer’s Name]By: ______________________________ ______________________Employer’s Representative Title