Consumer Authorization

To Whom It May Concern:

I hereby authorize and request any present or former employer, school, credit agency, financial institution,
law enforcement agency, city, state, county and federal court and agency, military service or other persons
having personal knowledge about me, to furnish bearer with any and all information in their possession
regarding me in connection with an application for employment. I am willing that a photocopy of this
authorization be accepted with the same authority as the original, and I specifically waive any written notice
from any present or former employer who may provide information based upon this authorized request. I
understand this authorization is to be part of the written employment application which I sign.
I have been given a stand alone, consumer notification that a report will be requested and used for the
purpose of evaluating me for employment, promotion, reassignment or retention as an employee.

Date:

Print Applicant Name:

Signature:

For Identification Purposes Only

Date of Birth:

Gender: Male Female

Previous Names Used:

Social Security Number

Driver’s License Number

State of Issue

Current Street Address

City, State, Zip Code

Contact Information

Home Phone:

Cell Phone:

Email Address
At any time an applicant is uncomfortable completing any portion of this form, please let us know and we will contact them directly for the
information that will remain confidential and only used for identification in the course of the investigation and will not be revealed to the
employer at any time. Give original to applicant and retain a copy for your files. (Also see "A Summary of Your Rights Under the Fair Credit
Reporting Act".

Por information en Espanol, visite www.consumerfinance.gov/leammore o escribe a la Consumer Financial Protection Bureay, 1700 G Street NW, Washington, DC 2006

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 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 the 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 20006.
 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/Jeammore 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 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, without your written consent given to
the employer. Written consent generally is not required in the trucking industry. For more information go to:
www.consumerfinance.gov/learmore.
 You may limit “prescreened” offers of credit and insurance you get based on information in your credit report.
Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if
you choose to remove your name and address from the lists these offers are based on. You may opt-out with
the nationwide credit bureaus at: 1-888-567-8688.
 You may seek damages from violators. If a consumer reporting agency or in some cases, a use of consumer
reports or furnisher of information from a consumer reporting agency violates the FCRA, you may be able to
sue in state or federal court.
 Identity theft victims and active duty military personnel have additional rights. For more information, visit
www.consumerfinance.gov/learnmore.
 States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases,
you may have more rights under state law. For more information, contact your state or local consumer
protection agency or your state Attorney General. For information about your federal rights, contact
www.consumerfinance.gov/learnmore.
 Type of Business Contact
1. a) Banks, Savings Associations a) Bureau of Consumer Financial Protection
Credit Unions with total assets of 1700 G Street N.W.
over $10 billion and their affiliates. Washington, DC 20006

b) Such affiliates that are not banks, b) Federal Trade Commission

savings associations or credit unions Consumer Response Center – FCRA
also should list, in addition to the Bureau Washington, DC 20580
(877) 382-4357
2. To the extent not included in item 1 above: a) Office of the Comptroller of the Currency
a) National banks, Federal Savings Customer Assistance Group
Associations, and Federal branches. 1301 McKinney Street, Suite 3450
Houston, TX 77010-9050

b) State member banks, branches and b) Federal Reserve Consumer Help Center
agencies of foreign banks (other than P.O. Box 1200
federal branches, federal agencies, Minneapolis, MN 55480
and insured state branches of foreign
banks, and organizations operating under
section 25 or 25A of the Federal Reserve Act

c) Nonmember Insured Banks, Insured State c) FDIC Consumer Response Center

Branches of Foreign Banks and insured 1100 Walnut Street, Box #112
state savings associations Kansas City, MO 64106

d) Federal Credit Unions d) National Credit Union Administration

Office of Consumer Protection (OCP)
Division of Consumer Compliance and
Outreach (DCCO)
1775 Duke Street
Alexandria, VA 20590
3. Air Carriers Assistant General Counsel for Aviation Enforcement &
Proceedings
Department of Transportation
400 Seventh Street SW
Washington, DC 20590
4. Creditors Subject to Surface Transportation Board Office of Proceedings
Surface Transportation Board
Department of Transportation
1925 K Street NW
Washington, DC 20423
5. Creditors Subject to Packers and Stockyards Act Nearest Packers and Stockyards Administration
Area Supervisor
6. Small Business Investment Companies Associate Deputy Administrator for Capital Access
United States Small Business Administration
406 Third Street, SW, 8th Floor
Washington, DC 20416
7. Brokers and Dealers Securities and Exchange Commission
100 F Street, NE
Washington, DC 20549
8. Federal Land Banks, Federal Land Bank Farm Credit Administration
Associations, Federal Intermediate Credit Banks, 1501 Farm Credit Drive
and Production Credit Associations McLean, VA 22102-5090
9. Retailers, Finance Companies, and all other FTC Regional Office for Region in which the Creditor
creditors not listed above operates or Federal Trade Commission