NOTICE, AUTHORIZATION AND RELEASE FOR THE PROCUREMENT OF A CONSUMER
AND/OR INVESTIGATIVE CONSUMER REPORT
I, the undersigned consumer, do hereby authorize The Maritime Aquarium at Norwalk, Inc., by and through its independent
contractor, KROLL BACKGROUND AMERICA, INC. (“KBA”)/HireRight, Inc., to procure a consumer report and/or investigative
consumer report on me. I understand that this authorization and release shall be valid for subsequent consumer and/or investigative
consumer reports during my period of employment with The Maritime Aquarium at Norwalk, Inc..
These above-mentioned reports may include, but are not limited to, information as to my character, general reputation, and personal
characteristics, discerned through employment and education verifications; personal references; personal interviews; my personal
credit history based on reports from any credit bureau; my driving history, including any traffic citations; a social security number
verification; present and former addresses; criminal and civil history/records; any other public record.
I further authorize any person, business entity or governmental agency who may have information relevant to the above to disclose the
same to The Maritime Aquarium at Norwalk, Inc., by and through KBA/HireRight, Inc., including, but not limited to any and all
courts, public agencies, law enforcement agencies and credit bureaus, regardless of whether such person, business entity or
governmental agency complied the information itself or received it from other sources.
I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any investigative consumer report of
which I am the subject upon my written request to KBA/HireRight, Inc., if such is made within a reasonable time after the date hereof.
I also understand that I may receive a written summary of my rights under 15 U.S.C. § 1681 et.seq.
Signature:_________________________________________________ Date:_______________________________
Parent or Guardian Signature:______________________________________Date:___________________________
IDENTIFYING INFORMATION FOR CONSUMER REPORTING AGENCY
Printed Name:________________________________________________________________________________________________
First Middle Last
Other Names Used (alias, maiden, nickname)_________________________________________________________
Years Used____________________________________________________________________________________
Current
Address:____________________________________________________________________________________________________
Street/P.O. Box City State Zip Code County Dates
Former
Address:____________________________________________________________________________________________________
Street/P.O. Box City State Zip Code County Dates
Social Security Number__________________________ Daytime Telephone Number__________________________________
Driver’s License Number:_______________________State of issuance_______*Date of Birth____________*Gender_____________
* This information will enable us to properly identify you in the event we find adverse information during the course of our
background search.
* This information will enable us to properly identify you in the event we find adverse information during the course of our
background search.
