Background Check Authorization Name First Name Last Name BACKGROUND CHECK AUTHORIZATION SEX OFFENDER REGISTRY CHECK: In compliance with Habitat for Humanity’s Quality Assurance standards, Tulsa Habitat for Humanity screens all potential staff, board members and applicant families on the National Sex Offender Public Registry. GREEN COUNTRY HABITAT RESERVES THE RIGHT AT ITS DISCRETION TO SCREEN ANY VOLUNTEER ON THE NATIONAL SEX OFFENDER PUBLIC REGISTRY. By completing this form you are consenting to such inquiry. I understand Green Country Habitat for Humanity requires all board members to consent to a criminal background check as a condition of service. If selected to serve on the Green Country Habitat for Humanity board, I agree to perform to the best of my abilities and means, the responsibilities, expectations and fundraising duties for board members I Agree DISCLOSURE AND AUTHORIZATION FOR CONSUMER REPORTS In connection with my application for employment/licensure (including contract or volunteer services) or application to rent a dwelling, I understand consumer reports will be requested by Green Country Habitat for Humanity. These reports may include, as allowed by law, the following types of information, as applicable: names and dates of previous employers, reason for termination of employment, work experience, reasons for termination of tenancy, former landlords, education, accidents, licensure, credit, etc. I further understand that such reports may contain public record information such as, but not limited to: my driving record, workers’ compensation claims, judgments, bankruptcy proceedings, evictions, criminal records, etc., from federal, state, and other agencies that maintain such records. In addition, investigative consumer reports (gathered from personal interviews, as applicable, with former employers or landlords, past or current neighbors and associates of mine, etc.) to gather information regarding my work or tenant performance, character, general reputation and personal characteristics, and mode of living (lifestyle) may be obtained. If I am hired/licensed, I understand that my employer can use this disclosure and authorization to continue to obtain such consumer reports throughout my employment/licensure, contract period or volunteer service. I Agree I hereby authorize procurement of consumer report(s) and investigative consumer report(s) by Company. If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for Company to procure such reports at any time during my employment/licensure, contract or volunteer period. I authorize without reservation, any person, business or agency contacted by the consumer reporting agency to furnish the above-mentioned information. This authorization is conditioned upon the following representations of my rights: I understand that I have the right to make a request to the Consumer Reporting Agency: AmericanChecked Inc., 4870 South Lewis Avenue, Suite 120, Tulsa, OK 74105; telephone: 800-975-9876 (“Agency”) upon proper identification, to obtain copies of any reports furnished to Company by the Agency and to request the nature and substance of all information in its files on me at the time of my request, including the sources of information, and the Agency, on Company’s behalf, will provide a complete and accurate disclosure of the nature and scope of the investigation covered by any investigative consumer report(s). The Agency will also disclose the recipients of any such reports on me which the Agency has previously furnished within the two year period for employment requests, and one year for other purposes preceding my request (California three years). I hereby consent to Company obtaining the above information from the Agency. I understand that I can dispute, at any time, any information that is inaccurate in any type of report with the Agency. I may view the Agency’s privacy policy at their website: http://americanchecked.com/privacy-policy. I understand that if the Company is located in California, Minnesota or Oklahoma, that I have the right to request a copy of any report the Company receives on me at the time the report is provided to the Company. By checking the following box, I request a copy of all such reports be sent to me. Please send a copy As a California applicant, I understand that I have the right under Section 1786.22 of the California Civil Code to contact the Agency during reasonable hours (9:00 a.m. to 5:00 p.m. (CST) Monday through Friday) to obtain all information in Agency’s file for my review. I may obtain such information as follows: 1) In person at the Agency’s offices, which address is listed above. I can have someone accompany me to the Agency’s offices. Agency may require this third party to present reasonable identification. I may be required at the time of such visit to sign an authorization for the Agency to disclose to or discuss Agency’s information with this third party; 2) By certified mail, if I have previously provided identification in a written request that my file be sent to me or to a third party identified by me; 3) By telephone, if I have previously provided proper identification in writing to Agency; and 4) Agency has trained personnel to explain any information in my file to me and if the file contains any information that is coded, such will be explained to me. I understand that if I am applying for employment in New York, that I have the right to receive a copy of Article 23-A of the New York Correction Law (initial if this applies). I understand that if the report is provided to an employer in the State of Washington, that I can contact the following office for more information regarding my rights under Washington State Law in regard to these reports: State of Washington Attorney General, Consumer Protection Division, 800 5th Ave, Ste. 2000, Seattle, Washington 98104-3188, (206) 464-7744. In connection with my application for employment/licensure (including contract or volunteer services) or application to rent a dwelling, I direct the following regarding my current employer: (please check one). Yes, my current employer may be contacted No, my current employer cannot be contacted I understand that I have rights under the Fair Credit Reporting Act, and I acknowledge receipt of the Summary of Rights I Understand Voluntary Self-Identification Form Green Country Habitat for Humanity is committed to fostering a diverse organization without regard to race, color, religion, sex, sexual orientation, national origins, citizenship, age, mental or physical disabilities, marital status, veteran/ reserve/national guard status or any other similarly protected status. As part of our compliance and reporting obligations, we invite you to self-identify gender and race/ ethnicity. Completion of this data is VOLUNTARY and will not affect your relationship with Green Country Habitat for Humanity. This form will remain confidential and will be kept separate from all other records. Refusal to complete this form will not subject you to any adverse treatment. What is your Gender? Male Female I choose not to self-identify What is your race/ethnicity? Please mark the box that describes the race/ethnicity category with which you primarily identify. Hispanic or Latino: a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. White (Not Hispanic or Latino): a person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American (Not Hispanic or Latino): a person having origins in any of the black racial groups of Africa. Asian (Not Hispanic or Latino): a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. American Indian or Alaska Native (Not Hispanic or Latino): a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. Two or More Races (Not Hispanic or Latino): a person who primarily identifies with two or more of the above race/ethnicity categories. I do not wish to disclose. CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK IN COMPLIANCE WITH THE FCRA (Fair Credit Reporting Act) AND DOT REGULATIONS Name First Name Last Name Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country Drivers License State Drivers License # Date of Birth (to be used only for criminal background check, and not part of the personal file) Social Security Number (to be used only for criminal background check, and not part of the personal file) This authorization and consent for release of personal information acknowledges that Tulsa Habitat for Humanity hereafter referred to as "Company" and/or its agent, Investigative Concepts, Inc., may now, or at any time I am assigned to or am employed by this Company, conduct investigations whether the records are of a public, private or confidential nature. These investigations might include, but are not limited to, searches of educational institutions attended; state driving records; records of previous employment, including work history, efficiency ratings, complaints and grievances filed by or against me; records and recollections of attorney-at-law or of other counsel, whether representing me or any other person (in either a civil or criminal case in federal agencies. After receiving an offer of employment, I understnad that a workers' compensation report may be obtained from either the Department of Labor, National Personnel Records, the Industrial Commission or similar agencies under the provisions of the Fair Credit Reporting Act 15, USC section 1681 et seq. I also authorize the National Personnel Records Center, or other custodian of my military service record, to release to Investigative Concepts, Inc. the following information and/or copies of documents from my military service record: DD214, service record, and any disciplinary record. I further authorize, in accordance to DOT Regulations, my DOT regulated drug and alcohol testing records, including but not limited to, information regarding any positive drug test, any refusal to be tested and any other violations of the DOT regulations, occuring in the previous 3 years. I authorize any and all records to be released to Investigative Concepts, Inc. I Agree I understand that these searches will be used to determine work assignment or employment eligibility under the Company's employment. Therefore, I authorize and consent for full release of records (either orally or in writing) to the authorized representatives of the Company. In addition, I release and discharge the Company and its agent and associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs, expenses or any other charge or complaint filed with any agency arising from retrieving and reporting this information. I understand that according to the Federal Fair Credit Reporting Act, I am entitled to know whether employment was denied based upon the information obtained and to receive, upon written request, a copy of the background report. I understand that I may request a copy of the report from Investigative Concepts, Inc, at P.O. Box 471832 Tulsa, OK or telephone number 918-286-7059. After reading this document, I fully understand its contents and authorize the background verification. I Understand and Agree I understand if I am applying for employment in Oklahoma, Minnesota or California I may request a copy of Consumer Report. To request a copy mark "yes" to the following. Yes, I request a copy of my consumer report I understand that if I am applying for employment in New York, that I have the right to receive a copy of Article 23-A of the New York Correction Law. To request a copy mark "yes" to the following. Yes, I request a copy of my consumer report I understand that if the report is provided to an employer in the State of Washington, that I can contact the State of Washington Attorney General, Consumer Protection Division, 800 5th Ave, Ste. 2000, Seattle, Washington 98104-3188, (206) 464-7744, for more information regarding my rights under state law. I Understand I hereby certify that all information provided in this automation is true, correct and complete. I understnad that if any information proves to be incorrect or incomplete that the grounds for the canceling of any and all offers of employment will exist and may be used at the discretion of the above listed company. MM DD YYYY Signature We have received your submission. Thank you!
