Applicant's Authorization and Release Printout for Signature with the Fair Credit Reporting Act Notice.
I hereby authorize and request any person or other entity, including but not limited to present and former employers, schools, law enforcement agencies, insurance companies, financial institutes, government agencies, including all entities which have information relating to my employment history, special training, worker's compensation, education, and credit history, to furnish the representative of IQM with any and all information and copies of records in their possession regarding me in connection with my employment application. I further authorize IQM to release the results of the background investigation to my prospective employer. By signing below, I hereby release and hold harmless the owners of IQM, and their client, and their directors, officers, employees, and agents from claims arising out of or in any connection with their legitimate gathering or disclosures of information as authorized by this release. I am willing that a copy of this Authorization and Release be accepted with the same authority as original. Supporting documents are reviewed by the witness.
Applicant's Name_________________________ Social Security Number ____/____/____
Applicant's Signature____________________________ Date____/____/____
Witness Signature_______________________________ Date____/____/____
FAIR CREDIT REPORTING ACT
DISCLOSURE AND AUTHORIZATION STATEMENT
NOTE: PLEASE READ CAREFULLY BEFORE SIGNING BELOW
For the purpose of evaluating my application for access authorization, I understand my prospective employer my obtain or have prepared a consumer report or investigative report concerning my prior employment, military record, education, credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, criminal background record, or mode of living.
I understand that upon written request to that employer, I will be informed whether an investigative consumer report was requested, and given full information as to the nature and scope of this investigation. (I understand that an investigative consumer report is a report in which information concerning my character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with neighbors, friends, or associates with whom I am acquainted).
By signing below, I am authorizing my prospective employer to obtain a consumer or investigative consumer report on me as part of the Company’s screening process for Employment. During the period in which I remain employed, I further authorize the Company to obtain additional consumer or investigative consumer reports on me to evaluate my trustworthiness and reliability for purposes of determining continuing employment.
By my signature below, I also acknowledge that I am entitled to a summary of my rights under the federal Fair Credit Reporting Act. The full document may be viewed on the Internet at: www.ftc.gov/os/statutes/fcra.htm.
Name of applicant: _________________________________________________
(please print)
Signature of applicant: _______________________________________________
Date signed: ________________________________
(For use with online submission)
Witness PIN Applicant's Last Name
Date of Birth Social Security Number
If you are submitting this form via the Internet, use your PIN in the "Witness PIN" box and date it. By doing this you are attesting that you have gathered and do possess the candidate's original signature on a printout of this form and that you have reviewed the candidate's supporting documents. Should a former employer or agency of inquiry require a copy of the original, an IQM agent will request that you fax a copy of the original authorization and release.
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