Applicant Disclosure Form

NOTICE – BACKGROUND INVESTIGATION AND USE OF CREDIT INFORMATION CALIFORNIA RESIDENTS 

California Residents or Employees – this summary of the provisions of California Civil Code section 1785.20.5 is being provided to you pursuant to state law.  

Prior to requesting a consumer credit report for employment purposes, the user of the report shall provide written notice to the person involved. The notice shall inform the person that a report will be used, and shall identify the specific basis under subdivision (a) of Section 1024.5 of California’s Labor Code for use of the report. The notice shall also inform the person of the source of the report, and shall contain a box that the person may check off to receive a copy of the credit report. If the consumer indicates that he or she wishes to receive a copy of the report, the user shall request that a copy be provided to the person when the user requests its copy from the credit reporting agency. The report to the user and to the subject person shall be provided contemporaneously and at no charge to the subject person.

California Labor Code section 1024.5 is provided below: 

1024.5. (a) An employer or prospective employer shall not use a consumer credit report for employment purposes unless the position of the person for whom the report is sought is any of the following: 

1. A Managerial position.
2. A Position in the state Department of Justice.
3. That of a sworn peace officer or other law enforcement position.
4. A Position for which the information contained in the report is required by law to be disclosed or obtained.
5. A Position that involves regular access, for any purpose other than the routine solicitation and processing of credit card applications in a retail establishment, to all of the following types of information of any one person:
   1. Bank or credit card account information.
   2. Social security number.
   3. Date of birth.
6. A Position in which the person is, or would be, any of the following:
   1. A named signatory on the bank or credit card account of the employer.
   2. Authorized to transfer money on behalf of the employer.
   3. Authorized to enter into financial contracts on behalf of the employer.
7. A Position that involves access to confidential or proprietary information, including a formula, pattern, compilation, program, device, method, technique, process or trade secret that (i) derives independent economic value, actual or potential, from not being generally known to, and not being readily ascertainable by proper means by, other persons who may obtain economic value from the disclosure or use of the information, and (ii) is the subject of an effort that is reasonable under the circumstances to maintain secrecy of the information.
8. A Position that involves regular access to cash totaling ten thousand dollars ($10,000) or more of the employer, a customer, or client, during the workday.

1. This section does not apply to a person or business subject to Sections 6801 to 6809, inclusive, of Title 15 of the United States Code and state and federal statutes or regulations implementing those sections if the person or business is subject to compliance oversight by a state or federal regulatory agency with respect to those laws.
2. The following definitions apply to this section:
3. “Consumer credit report” has the same meaning as defined in subdivision (c) of Section 1785.3 of the Civil Code, but does not include a report that (1) verifies income or employment, and (2) does not include credit-related information, such as credit history, credit score, or credit record.
4. “Managerial position” means an employee covered by the executive exemption set forth in subparagraph (1) of paragraph (A) of Section 1 of Wage Order 4 of the Industrial Welfare Commission (8 Cal. Code Regs. 11040).

NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW CALIFORNIA RESIDENTS 

California Residents or Employees – this summary of the provisions of California Civil Code section 1786.22 is being provided to you pursuant to state law.  

Your employer intends to obtain information about you from an investigative consumer reporting agency, as defined under California law, for employment purposes.  

Under California law you are entitled to visually inspect all files maintained about you by an investigative consumer reporting agency (“ICRA”), such as ClearStar, Inc – 5955 Shiloh Rd, East, Suite 104, Alpharetta, GA 3005. 1.877.275.7099, upon request and presentation of proper identification during normal business hours and on reasonable notice as follows:

• In person. You may request a copy of your file. The ICRA may charge you for the actual copying costs associated with providing you with a copy of your file.
• By telephone. A summary of all information contained in the ICRA’s file about you will be provided to you via telephone, if you have made a written request for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to you.
• By certified mail. You may make a written request for copies to be sent to a specified addressee. ICRA’s complying with requests for certified mailings shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the ICRA.

“Proper Identification” includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. If an ICRA is unable to reasonably identify you on the basis of these documents, they may require additional information concerning your employment and personal or family history in order to verify your identity.  

The ICRA will provide trained personnel to explain any information furnished to you and will provide a written explanation of any coded information contained in files maintained on you. This written explanation will be provided whenever a file is provided to you for visual inspection.  

You may be accompanied by one other person of your choosing, who must furnish reasonable identification. An ICRA may require you to furnish a written statement granting permission to the ICRA to discuss your file in such person’s presence. 

NOTICE – BACKGROUND INVESTIGATION NEW JERSEY RESIDENTS 

New Jersey Residents or Employees – this summary of the provisions of the New Jersey Fair Credit Reporting Act (“NJFCRA”) is being provided to you pursuant to state law (N.J.S.A. § 56:11-28 et seq.) 

• Before an employer can obtain a consumer report about you from a consumer reporting agency they must provide you with a clear and conspicuous disclosure in writing that such may be obtained for employment purposes. You must provide written consent to the procurement, for employment purposes, of a consumer report.
• When using a consumer report for employment purposes, before taking adverse action based in whole or in part on the report, an employer must provide you with a copy of the consumer report and a description in writing of your rights under the federal Fair Credit Reporting Act as well as the NJFCRA.
• You must be afforded a reasonable opportunity to dispute, with the consumer reporting agency, any information on which the employer relied upon in your consumer report.
• You can request from a consumer reporting agency all information in your file, upon proper identification. This includes sources of information and identification of each person who procured a consumer report for employment purposes during the two year period preceding your request. These requests must be made during normal business hours and on reasonable notice. It can be done in person or by telephone, if you have made a written request and pay the toll charge. A consumer reporting agency must provide trained personnel to explain to you any information in the consumer report.
• You can dispute inaccurate information with the consumer reporting agency. If you dispute the completeness or accuracy of any of the information in your file, the consumer reporting agency must reinvestigate free of charge during a

30-day period. A consumer reporting agency must provide written notice to you of the results of the reinvestigation not later than five business days after completion of the reinvestigation.

If, after a reinvestigation, any information disputed by you is found to be inaccurate or incomplete or cannot be verified, the consumer reporting agency must promptly delete that item of information from your file or modify that item of information, as appropriate, based on the results of the reinvestigation.

• You can seek damages for noncompliance under the NJFCRA.

NOTICE – BACKGROUND INVESTIGATION NEW YORK RESIDENTS 

New York Residents or Employees – this summary of the provisions of the New York Correction Law is being provided to you pursuant to state law. 

Article 23-A 

Licensure and Employment of Persons Previously Convicted of One or More Criminal Offenses 

§ 750. Definitions

For the purposes of this article, the following terms shall have the following meanings: 

1. “Public agency” means the state or any local subdivision thereof, or any state or local department, agency, board or commission.
2. “Private employer” means any person, company, corporation, labor organization or association which employs ten or more persons.
3. “Direct relationship” means that the nature of criminal conduct for which the person was convicted has a direct bearing on his fitness or ability to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in question.
4. “License” means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions or instrumentalities as a condition for the lawful practice of any occupation, employment, trade, vocation, business, or profession. Provided, however, that “license” shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire any explosive, pistol, handgun, rifle, shotgun, or other firearm.
5. “Employment” means any occupation, vocation or employment, or any form of vocational or educational training. Provided, however, that “employment” shall not, for the purposes of this article, include membership in any law enforcement agency.

§ 751. Applicability

The provisions of this article shall apply to any application by any person for a license or employment at any public or private employer, who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any license or employment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdiction preceded such employment or granting of a license, except where a mandatory forfeiture, disability or bar to employment is imposed by law, and has not been removed by an executive pardon, certificate of relief from disabilities or certificate of good conduct. Nothing in this article shall be construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with an application for employment made by a prospective employee or previously made by a current employee. 

§ 752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited

No application for any license or employment, and no employment or license held by an individual, to which the provisions of this article are applicable, shall be denied or acted upon adversely by reason of the individual’s having been previously convicted of one or more criminal offenses, or by reason of a finding of lack of “good moral character” when such finding is based upon the fact that the individual has previously been convicted of one or more criminal offenses, unless: 

1. there is a direct relationship between one or more of the previous criminal offenses and the specific license or employment sought or held by the individual; or
2. the issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk to property or to the safety or welfare of specific individuals or the general public.

§ 753. Factors to be considered concerning a previous criminal conviction; presumption

1. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall consider the following factors:

2. A The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons previously convicted of one or more criminal offenses. 
3. The specific duties and responsibilities necessarily related to the license or employment sought or held by the person. 
4. The bearing, if any, the criminal offense or offenses for which the person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities. 
5. The time which has elapsed since the occurrence of the criminal offense or offenses. 
6. The age of the person at the time of occurrence of the criminal offense or offenses. 
7. The seriousness of the offense or offenses. 
8. Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct. 
9. The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of specific individuals or the general public. 
10.  In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein.

§ 754. Written statement upon denial of license or employment

At the request of any person previously convicted of one or more criminal offenses who has been denied a license or employment, a public agency or private employer shall provide, within thirty days of a request, a written statement setting forth the reasons for such denial. 

§ 755. Enforcement

1. In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to article seventy-eight of the civil practice law and rules.
2. In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights pursuant to the powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city commission on human rights.

NOTICE – BACKGROUND INVESTIGATION WASHINGTON STATE RESIDENTS 

Washington State Residents or Employees – this summary of the provisions of the Washington State Fair Credit Reporting Act 

(WFCRA) is being provided to you pursuant to state law. The WFCRA is designed to promote accuracy, fairness, consumer confidentiality and the proper use of credit data by each consumer reporting agency (CRA) in accordance with the requirements of the WFCRA. 

The WFCRA is modeled after, and generally provides the same rights as, the federal Fair Credit Reporting Act (FCRA) (15 U.S.C. § 1681 et seq.)  

The complete text of the WFCRA RCW 19.182, can be obtained from the Washington Code Revisers Office, P.O. Box 40551, Olympia, WA 98504, or online at http://apps.leg.wa.gov/rcw/default.aspx?cite=19.182&full=true%20-%2019.182.070. One significant distinction between the FCRA and the WFCRA is that in Washington, an employer may not obtain a consumer report that indicates the consumer’s credit worthiness, credit standing, or credit capacity, unless (1) the information is substantially job related and the employer’s reason(s) for using the information are disclosed in writing, or (2) the information is required by law. 

The following is a summary of your major rights under the WFCRA: 

• You will be required to provide proper identification before reviewing your consumer file. Proper identification may include your Social Security number. You may request to review your file at any time. A CRA will make disclosures of your file available to you during normal business hours and on reasonable notice. File disclosures may be done in person or by telephone, if you have made a written request and pay the toll charge, as applicable, or by any other reasonable means. A CRA will provide trained personnel to explain to you any information in your consumer report. Upon request, and proper identification, you may be permitted to bring one additional person with you to review your consumer file. If the CRA provides you with a credit score, the agency will also provide you with an explanation for that credit score.
• You have a right to know what is in your file. Upon proper identification, you may request and obtain all the information about you in the CRA’s files, although medical information may be withheld, and instead will be disclosed to a health care provider of your choice. Your health care provider may disclose your medical information to you directly. Your file disclosure will include all items of information the CRA maintains about you, including sources of information (except sources acquired solely for use in an investigative report). The file will also identify each person who procured your consumer report for employment purposes during the two-year period preceding your request, or any person who procured your report for any other purpose within the six-months prior to your request. When applicable, a record of inquiries the CRA received identifying you in a credit transaction that was not initiated by you in the six-months prior to your file disclosure request. Each of these records will include the name of the person or trade name of the business that sought your consumer file, and upon your request, their respective addresses.
• You are entitled to one free consumer report every 12 months, upon request. In many cases, your file disclosure will be free. You may be charged a limited fee for a second or subsequent report requested by you during a 12 month period. You will also not be charged for:
  • a consumer report if a person has taken adverse action against you because of information in your report;
  • the reinvestigation of information you dispute; or
  • corrected reports resulting from the deletion of inaccurate or unverifiable information.
• You must be told if information in your file has been used against you. If a person takes an adverse action against you that is based, in whole or in part, on information contained in a consumer report, that person must tell you (usually, through a written notice), and must give you the name, address, and telephone number of the CRA that provided the information.
• You have a right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and you notify the CRA directly of the dispute, the CRA will reinvestigate without charge and record the current status of the disputed information before the end of thirty business days, unless your dispute is frivolous. Upon completion of the reinvestigation, within five business days of the CRA’s decision, the agency will provide you notice in writing or through another authorized means, of the results of the reinvestigation. If the CRA determines that your dispute is frivolous the agency will inform you of that determination, along with its reasons, and your rights under the WFCRA within five business days.
• Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Upon completion of the reinvestigation, if the information you disputed is found to be inaccurate or cannot be verified, the CRA must delete the information and notify you of the correction. Information that has been found to be inaccurate will not be reinserted into your consumer file, unless the furnisher of the information verifies the accuracy and completeness of that information. In such circumstances, you will be notified, within thirty business days that the information is being reinserted into your file. If the reinvestigation does not resolve your dispute, you may file with the CRA a brief statement (that may be limited to 100 words) setting forth the nature of your dispute. The statement will be placed in your consumer file and in any subsequent report containing the information you disputed.
• You have the right to request that users of your consumer report be notified of any disputed information they previously received within the statutory time frame. After certain disputed information has been deleted or you have filed a statement of dispute, you may request that the CRA provides notification of that deleted item or item of dispute to any person you designate who has, within two years received your consumer report for employment purposes, or who has within six months received your report for any other purpose, if the furnished report contained the deleted or disputed information.
• Consumer reporting agencies may not report outdated negative information. In most cases, a CRA may not report negative information that is more than seven years old, or bankruptcies that are more than ten years old.
• You have the right to advanced disclosure of any fees. Any charges for file disclosures or other requested actions to be taken by the CRA must be disclosed to you before the information is provided or the action is taken.
• Access to your file is limited. A CRA may provide information about you only to people with a valid need – usually to consider an application with a creditor, insurer, employer, landlord, court or government agency, or in accordance with your written instructions.
• You must be notified if reports are provided to employers. A CRA may not give out information about you to employers without your knowledge. A potential employer must make a clear and conspicuous disclosure in writing to you or obtain your consent before obtaining a report. A current employer may not receive a report unless it has given you written notice that reports may be used for employment purposes.
• You must be notified in writing if a person seeks an investigative consumer report about you. An investigative consumer report may include information as to your character, general reputation, personal characteristics, and mode of living. Within a reasonable period of time after receiving such notice, you may request, in writing, a disclosure as to the nature and scope of the investigation requested—which will be delivered to you within five days of your request.
• You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. You may elect not to receive unsolicited “prescreened” offers for credit and insurance by using the CRA’s notification system to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).

You may place a security freeze on your credit report. Under certain circumstances, you may request that a security freeze be placed on your credit report to prevent it from being shared with potential creditors or insurance companies when making determinations related to your eligibility for credit.

• You may be able to block information resulting from identity theft from appearing on your credit report. If you are a victim of identity theft, certain CRAs must permanently block misinformation resulting from that theft from appearing on your credit report. You must provide the CRA with a copy of a police report as evidence of your claim before it can place the block on your report.
• You may seek damages from violators. If a CRA, a user of consumer reports, or a furnisher of information to a CRA violates the WFCRA, and you have a legal basis for a claim under the WFCRA, you may be able to bring a legal action in court to assert your rights under the WFCRA. The applicable statute of limitations is specified in Wash. Stat. § 19.182.120 — which is generally two years from the date the cause of action accrued. Consumers who prevail on claims to enforce the WCFRA may obtain actual damages, monetary penalties, reasonable attorneys’ fees, costs, and other relief.

For questions or concerns regarding the WFCRA, please contact: 

Office of the Attorney General 

Consumer Protection Division 

800 5th Avenue, Suite 2000 

Seattle, Washington 98104-3188 

Phone 1-800-551-4636 or (206) 464-6684 

Statewide Toll-Free TDD: 800-833-6388 

Any complaints by consumers under state law may be directed to: 

The Attorney General’s Office via U.S. Mail or Online. 

Information and forms related to filing a consumer complaint can be found at: http://www.atg.wa.gov/FileAComplaint.aspx 

Additional information about consumer issues can be found at: 

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:
  • a person has taken adverse action against you because of information in your credit report;
  • you are the victim of identity theft and place a fraud alert in your file;
  • your file contains inaccurate information as a result of fraud;
  • you are on public assistance;
  • 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, 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/learnmore.

A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT 2 

• 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 1-888-5-OPTOUT (1-888-567-8688).
• The following FCRA right applies with respect to nationwide consumer reporting agencies:

CONSUMERS HAVE THE RIGHT TO OBTAIN A SECURITY FREEZE 

You have a right to place a “security freeze” on your credit report, which will prohibit a consumer reporting 

agency from releasing information in your credit report without your express authorization. The security 

freeze is designed to prevent credit, loans, and services from being approved in your name without your consent. However, you should be aware that using a security freeze to take control over who gets access to the personal and financial information in your credit report may delay, interfere with, or prohibit the timely approval of any subsequent request or application you make regarding a new loan, credit, mortgage, or any other account involving the extension of credit. 

As an alternative to a security freeze, you have the right to place an initial or extended fraud alert on your credit 

file at no cost. An initial fraud alert is a 1-year alert that is placed on a consumer’s credit file. Upon seeing a fraud alert display on a consumer’s credit file, a business is required to take steps to verify the consumer’s identity before extending new credit. If you are a victim of identity theft, you are entitled to an extended fraud alert, which is a fraud alert lasting 7 years. 

A security freeze does not apply to a person or entity, or its affiliates, or collection agencies acting on behalf of the person or entity, with which you have an existing account that requests information in your credit report for the purposes of reviewing or collecting the account. Reviewing the account includes activities related to account maintenance, monitoring, credit line increases, and account upgrades and enhancements. 

• 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.
• 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: