Background Options

Background Check Disclosure and Authorization Form

In the interest of maintaining the safety and security of our customers, employees and property, "The “Company” will order a “consumer report” (a background report) or “investigative consumer report" on you in connection with your employment application, and if you are hired, or if you already work for the Company, may order additional background reports on you for employment purposes. \The background check company, STATEWIDE SECURITY AND SAFETY GROUP, LLC (The "Background Check Company"), will prepare the Background report for the Company. The Background Check Company is located at 8012 S. ASHLAND AVE. CHICAGO, IL 60620 , and can be Reached by phone at 773-701-4032 or at their Internet Web site address WWW.SWSSGROUP.COM. The background report may contain information concerning your character, general reputation, personal characteristics, mode of living, and credit standing. The types of information that may be ordered include but are not limited to: Social Security number verification; criminal, public, educational and, as appropriate, driving records checks; verification of prior employment; reference, licensing and certification checks; credit reports; drug testing results; and, if applicable, worker’s compensation injuries. Workers’ compensation information will only be requested in compliance with federal Americans with Disabilities Act and/or any other applicable federal, state or local laws and only after a conditional job offer is made. Credit history will only be requested when permitted by law and where such information is substantially related to the duties and responsibilities of the position for which you are applying. The information may be obtained from private and public record sources, including personal interviews with your associates, friends, and neighbors. (An “investigative consumer report” is a background report that includes information from such personal interviews, except in California where that term means any background report that is not a credit report.) The nature and scope of the most common form of investigative consumer report is an investigation into your education and/or employment history conducted by the Background Check Company or another outside organization. You may request more information about the nature and scope of an investigative consumer report, if any, by telephoning the Company at 773-701-4032. A summary of your rights under the Fair Credit Reporting Act is also being provided to you with this form. The Fair Credit Reporting Act gives you specific rights in dealing with consumer reporting agencies. You will find these rights summarized on A Summary of Your Rights Under the Fair Credit Reporting Act and A Summary of Your Rights Under the Provisions of California Civil Code Section 1786.22 for California residents..

Consent*

I agree

After carefully reading this Background Check Disclosure and Authorization form, I authorize the Company to order my background report, including investigative consumer reports. I understand that the Company may rely on this authorization to order additional background reports, including investigative consumer reports, during my employment without asking me for my authorization again as allowed by law.

I also authorize the following agencies and entities to disclose to the Background Check Company and its agents all information about or concerning me, including but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; if applicable, worker’s compensation injuries; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. Workers’ compensation information will only be requested in compliance with federal Americans with Disabilities Act and/or any other applicable federal, state or local laws and only after a conditional job offer is made. The information that can be disclosed to the Background Check Company and its agents includes, but is not limited to, information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses and substance abuse testing.

I agree the Company may rely on this authorization to order background reports, including investigative consumer reports, from companies other than the Background Check Company without asking me for my authorization again as allowed by law. I also agree that a copy of this form is valid like the signed original. I certify that all of the personal information I provided is true and correct.

Background Check Disclosure and Authorization Form

Agency*

Name*

First Middle Last

Date of Birth*

Social Security

Driver's License Number*

State Issuing License*

Prior Name

First Middle Last

Enter Any Other Names Used (including maiden names):

Prior Name

First Middle Last

Enter Any Other Names Used (including maiden names):

Addresses within the Past Seven Years

Present Address*

Street Address Address Line 2 City State ZIP Code

Prior Address

Street Address Address Line 2 City State ZIP Code

Prior Address

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Upload Driver License/State ID*

Accepted file types: png, jpg, jpeg, gif, pdf, Max. file size: 100 MB.

Any signature (including any electronic symbol or process attached to, or associated with, a contract or other record and adopted by a Person with the intent to sign, authenticate or accept such contract or record) hereto or to any other certificate, agreement or document related to this transaction, and any contract formation or record-keeping through electronic means shall have the same legal validity and enforceability as a manually executed signature or use of a paper-based recordkeeping system to the fullest extent permitted by applicable law, including the Federal Electronic Signatures in Global and National Commerce Act, the New York State Electronic Signatures and Records Act, or any similar state law based on the Uniform Electronic Transactions Act, and the parties hereby waive any objection to the contrary.

Electronic Signature*

First Last

Date*