5.10.05 Page 1 of 2 INVESTIGATIVE CONSUMER REPORT DISCLOSURE In connection with your employment or application for employment (including contract for services), an investigative consumer report and consumer reports, which may contain public record information, may be requested from USIS Commercial Services ( cUSIS d). These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, academic history, professional credentials, drugs/alcohol use, information relating to your character, general reputation, personal characteristics, mode of living, educational background, or any other information about you which may reflect upon your potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. Such reports may contain public record information concerning your driving record, workers 9 compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from USIS concerning previous driving record requests made by others from such state agencies.
Oklahoma Applicants Only: I request a copy of any credit report requested on me. Minnesota Applicants Only: I request a copy of any consumer report requested on me. You have ... more. less.
the right to receive, upon your written request within a reasonable period of time, (not to exceed 30 days) a complete and accurate disclosure of the nature and scope of the investigation requested.<br><br> You have the right to make a request to USIS, upon proper identification, to request the nature and substance of all information in its files on you at the time of your requ est, including the sources of information, and the recipients of any reports on you that USIS has previously furnished within the two-year period preceding your request. USIS may be contacted by mail at P.O. Box 33181, Tulsa, Oklahoma, 74153, or by phone at (800) 381-0645.<br><br> Attached to this disclosure is a written summary of your rights under the Fair Credit Reporting Act (FCRA) as prepared by the Federal Trade Commission. Print Applicant/Employee Full Name Date Applicant/Employee Signature Notice to California Applicants Under California law, the consumer reports we order on you for employment purposes within the State of California are defined a s investigative consumer reports. These reports may contain information on your character, general reputation, personal characteristics and mod e of living.<br><br> Under section 1786.22 of the California Civil Code, you may view the file maintained on you by USIS during normal business hours. Yo u may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services, by appearing at USIS in p erson, by mail, or by telephone. USIS may be contacted by mail at P.O.<br><br> Box 33181, Tulsa, Oklahoma, 74153, or by phone at (800) 318-0645. The agency is required to have personnel available to explain your file to you and the agency must explain to you any coded information appearing in your file. If you appear in person, a person of your choice may accompany you, provided that this person furnishes proper identification.<br><br> I request to receive a free copy of any investigative consumer report ordered on me by checking this box. (California applicants only) 5.10.05 Page 2 of 2 INVESTIGATIVE CONSUMER REPORT RELEASE Pursuant to the Investigative Consumer Report Disclosure previously delivered to me, I authorize USIS Commercial Services to pr epare a consumer report or investigative consumer report about me for employment-related purposes. I have been provided a copy of the summary of the rights of the consumer pursuant to the Fair Credit Reporting Act (FCRA).<br><br> I hereby fully release and discharge USIS, their respective affiliates, subsidiaries, directors, officers, employees, agents an d attorneys thereof, and each of them, and any individual, organization, entity, agency, or other source providing information to USIS from all clai ms and damages arising out of or relating to any investigation of my background for employment purposes. This release is valid for al l federal, state, county and local agencies, authorities, previous employers, military services and educational institutions. USIS is authorized to disclose all information obtained to the requesting entity for the purpose of making a determination as t o my eligibility for employment, promotion or any other lawful purpose.<br><br> I agree that such information which USIS has or obtains, and my employm ent history if I am hired, may be supplied by USIS to other companies that subscribe to USIS. If hired or contracted, this authori zation shall remain on file and shall serve as ongoing authorization for the procurement of consumer reports at any time during my employmen t or contract period. Oklahoma Applicants Only: I request a copy of any credit report requested on me.<br><br> Minnesota Applicants Only: I request a copy of any consumer report requested on me. By signing below, I certify that I have read and fully understand this release, that prior to signing I was given an opportunit y to ask questions and to have those questions answered to my satisfaction, and that I executed this release voluntarily and with the knowledge th at the information being released could affect my being hired, my employment, or my eligibility for promotion. Today 9s Date ________________________ Signature Print your full name For purposes of gathering this information, I agree to supply the following information, which may be required by law enforceme nt agencies and other entities for positive identification purposes when checking records.<br><br> It is confidential and will not be used for any other purpose. Print other last names you have used List States and Counties of Residence for the past: 3 years 5 years 7 years 10 years (Attach a separate sheet if more space is needed.) State _________________City/County __________________________________________ From ________ to ________ State _________________City/County __________________________________________ From ________ to ________ State _________________City/County __________________________________________ From ________ to ________ State _________________City/County __________________________________________ From ________ to ________ Home Address City ______________________________________________ State ______________________ Zip Social Security No. _________________________________ Date of Birth Driver 9s License No.<br><br> ________________________________ State Issuing License Sex: Male Female Race: Asian Black Hispanic White Other _____________________________ (circle one) (circle one) Company Name : _________________________ Location No .: ______________ Company Code : _____________ Notice to California Applicants Under California law, the consumer reports we order on you for employment purposes within the State of California are defined a s investigative consumer reports. These reports may contain information on your character, general reputation, personal characteristics and mod e of living. Under section 1786.22 of the California Civil Code, you may view the file maintained on you by USIS during normal business hours.<br><br> Yo u may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services, by appearing at USIS in p erson, by mail, or by telephone. USIS may be contacted by mail at P.O. Box 33181, Tulsa, Oklahoma, 74153, or by phone at (800) 318-0645.<br><br> The agency is required to have personnel available to explain your file to you and the agency must explain to you any coded information appearing in your file. If you appear in person, a person of your choice may accompany you, provided that this person furnishes proper identification. I request to receive a free copy of any investigative consumer report ordered on me by checking this box.<br><br> (California applicants only) Para informacion en espanol, visite www.ftc.gov/credit o escribe a la FTC Consumer Response Center, Room 130-A 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.<br><br> 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.<br><br> For more information, including information about additional rights, go to www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.<br><br> C 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 3 or to take another adverse action against you 3 must tell you, and must give you the name, address, and phone number of the agency that provided the information. C You have the right to know what is in your file.<br><br> You may request and obtain all the information about you in the files of a consumer reporting agency (your cfile disclosure d). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free.<br><br> You are entitled to a free file disclosure if: C a person has taken adverse action against you because of information in your credit report; C you are the victim of identify theft and place a fraud alert in your file; C your file contains inaccurate information as a result of fraud; C you are on public assistance; C you are unemployed but expect to apply for employment within 60 days. In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.ftc.gov/credit for additional information.<br><br> C 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.<br><br> In some mortgage transactions, you will receive credit score information for free from the mortgage lender. C 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.<br><br> See www.ftc.gov/credit for an explanation of dispute procedures. C 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.<br><br> However, a consumer reporting agency may continue to report information it has verified as accurate. C 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.<br><br> C 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.<br><br> C 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.<br><br> For more information, go to www.ftc.gov/credit . C You may limit cprescreened d offers of credit and insurance you get based on information in your credit report. Unsolicited cprescreened d 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.<br><br> You may opt-out with the nationwide credit bureaus at 1-8 88 - 567-8688. C You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.<br><br> C Identity theft victims and active duty military personnel have additional rights. For more information, visit www.ftc.gov/credit . States may enforce the FCRA, and many states have their own consumer reporting laws.<br><br> 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. Federal enforcers are: TYPE OF BUSINESS: CONTACT: Consumer reporting agencies, creditors and others not listed below Federal Trade Commission: Consumer Response Center - FCRA Washington, DC 20580 1-877-382-4357 National banks, federal branches/agencies of foreign banks (word "National" or initials "N.A." appear in or after bank's name) Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC 20219 800-613-6743 Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks) Federal Reserve Board Division of Consumer & Community Affairs Washington, DC 20551 202-452-3693 Savings associations and federally chartered savings banks (word "Federal" or initials "F.S.B." appear in federal institution's name) Office of Thrift Supervision Consumer Complaints Washington, DC 20552 800-842-6929 Federal credit unions (words "Federal Credit Union" appear in institution's name) National Credit Union Administration 1775 Duke Street Alexandria, VA 22314 703-519-4600 State-chartered banks that are not members of the Federal Reserve System Federal Deposit Insurance Corporation Consumer Response Center, 2345 Grand Avenue, Suite 100 Kansas City, Missouri 64108-2638 1-877-275-3342 Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission Department of Transportation , Office of Financial Management Washington, DC 20590 202-366-1306 Activities subject to the Packers and Stockyards Act, 1921 Department of Agriculture Office of Deputy Administrator - GIPSA Washington, DC 20250 202-720-7051<br><br>