EMPLOYER SOLUTIONS STAFFING GROUP
BACKGROUND CHECK AUTHORIZATION
Employee Name:
(First) (Middle) (Last)
Former Name(s) and Dates Used:
Current Address Since:
(Mo/Yr) (Street) (City) (State/Zip)
Previous Address From:
(Mo/Yr) (Street) (City) (State/Zip)
Previous Address From:
(Mo/Yr) (Street) (City) (State/Zip)
Social Security Number: DOB:
Phone Number:
Driver’s License Number/State:
The information contained in this application is correct to the best of my knowledge.
I hereby authorize Employer Solutions Staffing Group, LLC and its designated agents and representatives to conduct a
comprehensive review of my background causing a consumer report and/or an investigative consumer report to be
generated for employment purposes. I understand that the scope of the consumer report/ investigative consumer
report may include, but is not limited to the following areas: verification of social security number; credit reports,
current and previous residences; employment history, education background, character references; drug testing, civil
and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving
records, birth records, and any other public records.
I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal
or written, pertaining to me, to Employer Solutions Staffing Group, LLC or its agents. I further authorize the complete
release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may
have, to include information or data received from other sources. Employer Solutions Staffing Group, LLC and its
designated agents and representatives shall maintain all information received from this authorization in a confidential
manner in order to protect the applicants personal information, including, but not limited to, addresses, social security
numbers, and dates of birth.
Signature: Date:
Notice to CA, MN, and OK Residents:
Please check the box below if you wish to receive a copy of a consumer report that is requested.
I wish to receive a copy of any Background Check Report on me that is requested.
Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la Consumer
Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
A Summary of Your Rights Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of
information in the files of consumer reporting agencies. There are many types of consumer reporting
agencies, including credit bureaus and specialty agencies (such as agencies that sell information about
check writing histories, medical records, and rental history records). Here is a summary of your major
rights under FCRA. For more information, including information about additional rights, go to
www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G
Street N.W., Washington, DC 20552.
You must be told if information in your file has been used against you. Anyone who uses a
credit report or another type of consumer report to deny your application for credit, insurance, or
employment – or to take another adverse action against you – must tell you, and must give you
the name, address, and phone number of the agency that provided the information.
You have the right to know what is in your file. You may request and obtain all the
information about you in the files of a consumer reporting agency (your “file disclosure”). You
will be required to provide proper identification, which may include your Social Security number.
In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
o a person has taken adverse action against you because of information in your credit
report;
o you are the victim of identity theft and place a fraud alert in your file;
o your file contains inaccurate information as a result of fraud;
o you are on public assistance;
o you are unemployed but expect to apply for employment within 60 days.
In addition, all consumers are entitled to one free disclosure every 12 months upon request from each
nationwide credit bureau and from nationwide specialty consumer reporting agencies. See
www.consumerfinance.gov/learnmore for additional information.
You have the right to ask for a credit score. Credit scores are numerical summaries of your
credit-worthiness based on information from credit bureaus. You may request a credit score from
consumer reporting agencies that create scores or distribute scores used in residential real
property loans, but you will have to pay for it. In some mortgage transactions, you will receive
credit score information for free from the mortgage lender.
You have the right to dispute incomplete or inaccurate information. If you identify
information in your file that is incomplete or inaccurate, and report it to the consumer reporting
agency, the agency must investigate unless your dispute is frivolous. See
www.consumerfinance.gov/learnmore for an explanation of dispute procedures.
Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable
information. Inaccurate, incomplete, or unverifiable information must be removed or corrected,
usually within 30 days. However, a consumer reporting agency may continue to report
information it has verified as accurate.
Consumer reporting agencies may not report outdated negative information. In most cases,
a consumer reporting agency may not report negative information that is more than seven years
old, or bankruptcies that are more than 10 years old.
Access to your file is limited. A consumer reporting agency may provide information about you
only to people with a valid need – usually to consider an application with a creditor, insurer,
employer, landlord, or other business. The FCRA specifies those with a valid need for access.
You must give your consent for reports to be provided to employers. A consumer reporting
agency may not give out information about you to your employer, or a potential employer,
