Consent to Perform Criminal & Credit History I Background Checks
In Compliance with the FCRA (Fair Credit Reporting Act)


*AS SHOWN ON THE ORIGINAL APPLICATION
**TO BE USED FOR CRIMINAL & CREDIT HISTORY CHECKS ONLY AND NOT A PART OF THE PERSONNEL FILE.

, am an applicant for employment / volunteerism with Company and have been advised that as a part of the application process, the company conducts a criminal and credit history background check. I do hereby consent to the company use of any information provided during the application process in performing the criminal and credit history check. The company has informed me that I have the right to review and challenge any negative information that would adversely impact a decision to offer employment / volunteerism. In addition, I have been informed that I will have a reasonable opportunity to clear up any mistaken information reported within a reasonable time frame established within the sole discretion of the company. Under the Fair Credit Reporting Act, I have been advised that upon request I will be provided the name, address and telephone number of the reporting agency as well as the nature, substance and source of all information.


The following are my responses to questions about my criminal history (if any).

1.

Have you ever been convicted or plead guilty before a court for any federal, state or municipal criminal offense? (exclude minor traffic misdemeanors). If yes, please provide details below.


2.

No Have you ever received deferred adjudication or similar disposition for any federal, state or municipal offense? If yes, please provide details below.


3.

No Have you ever received probation or community supervision for any federal, state or municipal offense?