ࡱ> knj{ ?bjbjzz Hd26v v 8LhL66(^^^ 6 6 6 6 6 6 6$:<0606^^4E6$$$^^ 6$ 6$$J3h4^ /H35[6063=_!= 44=4\N$l@0606I#6=v : INVESTIGATIVE CONSUMER REPORT AND CONSUMER REPORT DISCLOSURE & CONSENT FORM Company Name: Sample Company (Requesting Entity) In connection with your employment or application for employment (or contract for services) and any future employment (or contract for services) with Requesting Entity you may have, investigative consumer reports and consumer reports, which may contain public record information may be requested from Promesa Enterprises, Inc. dba Integrated Screening Partners (ISP). 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, criminal information, educational background, or any other information about you which may reflect upon your potential for employment or contract work 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, credit and bankruptcy proceedings (California/Colorado require additional notice/consent), criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from ISP such as previous driving record requests made by others from such state agencies or previous drug/alcohol tests and the results of such tests. Such reports may also contain medical information from physicals relevant to process or effect the employment. You have the right to receive, upon your written request within a reasonable period of time a complete and accurate disclosure of the nature and scope of the investigation requested. You have the right to make a request to ISP, upon proper identification, to request the nature and substance of all information in its files on you at the time of your request, including the sources of information, and the recipients of any reports on you that ISP has previously furnished within the two-year period preceding your request. ISP may be contacted by mail at: Integrated Screening Partners Attn: Consumer Department 5316 Hwy. 290-Suite 500, Austin, TX 78735, or by phone at 800-474-4420. Information about ISPs privacy practices may be found at http://www.integratedscreening.com/privacy.asp New York Applicants Only: I acknowledge receipt of a copy of Article 23-A of New York Correction Law.  FORMCHECKBOX  Oklahoma Applicants Only: I request a copy of any consumer report requested on me.  FORMCHECKBOX  Minnesota Applicants Only: I request a copy of any consumer report requested on me. Notice to California Applicants Under California law, the consumer reports we order on you for employment purposes within the State of California are defined as investigative consumer reports. These reports may contain information on your character, general reputation, personal characteristics and mode of living. Under section 1786.22 of the California Civil Code, you may view the file maintained on you by ISP during normal business hours. You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services, by appearing at ISP in person, by mail, or by telephone. ISP may be contacted by mail at ISP Attn: Consumer Department 5316 Hwy. 290-Suite 500, Austin, TX 78735, or by phone at 800-474-4420. 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.  FORMCHECKBOX  I request to receive a free copy of any investigative consumer report ordered on me by checking this box. (California applicants only) Attached to this disclosure is a written summary of your rights under the Fair Credit Reporting Act (FCRA) as prepared by the Consumer Financial Protection Bureau. Authorization for ALL Applicants I authorize and instruct ISP to prepare a consumer report or investigative consumer report and to disclose all information obtained to the Requesting Entity including relevant medical information, for the purpose of making a determination as to my eligibility for initial or continued employment (or contract for services), promotion, reassignment, retention or any other lawful purpose. I have been provided a copy of the summary of the rights of the consumer pursuant to the Fair Credit Reporting Act (FCRA). If hired or contracted, this authorization shall remain on file and shall serve as ongoing authorization for the procurement of consumer reports at any time during my employment or contract period. By signing below, I certify that I have carefully read and understand this Disclosure and Consent form, and that I executed this release voluntarily and with the knowledge that the information being released could affect my being hired, my employment, or my eligibility for promotion. Todays Date _______________ Signature Social Security Number: _________-_______-________ Print your full name Date of Birth: _________________________________________ Street Address ___________________________________________ City__________________ State__________ Zip Code_________________ Para informacion en espanol, visite  HYPERLINK "http://www.consumerfinance.gov/learnmore" 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 the 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  HYPERLINK "http://www.napbs.com/files/events/Webinars/www.consumerfinance.gov/learnmore" 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  HYPERLINK "http://www.napbs.com/files/events/Webinars/www.consumerfinance.gov/learnmore" 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  HYPERLINK "http://www.napbs.com/files/events/Webinars/www.consumerfinance.gov/learnmore" www.consumerfinance.gov/learnmore. 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 1-888-567- 8688. 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  HYPERLINK "http://www.napbs.com/files/events/Webinars/www.consumerfinance.gov/learnmore" 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: TYPE OF BUSINESS: 1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates. b. Such affiliates that are not banks, savings associations, or credit also should list, in addition to the Bureau: 2. To the extent not included in item 1 above: a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and insured state branches of foreign banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations d. Federal Credit Unions 3. Air carriers 4. Creditors Subject to Surface Transportation Board 5. Creditors Subject to Packers and Stockyards Act 6. Small Business Investment Companies 7. Brokers and Dealers 8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations 9. Retailers, Finance Companies, and All Other Creditors Not Listed AboveCONTACT: a. Consumer Financial Protection Bureau 1700 G Street NW Washington, DC 20552 b. Federal Trade Commission: Consumer Response Center FCRA Washington, DC 20580 (877) 382-4357 a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050 b. Federal Reserve Consumer Help Center P.O. Box 1200 Minneapolis, MN 55480 c. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106 d. National Credit Union Administration Office of Consumer Protection (OCP) Division of Consumer Compliance and Outreach (DCCO) 1775 Duke Street Alexandria, VA 22314 Asst. General Counsel for Aviation Enforcement & Proceedings Department of Transportation Aviation Consumer Protection Division 1200 New Jersey Avenue S.E. Washington, DC 20590 Office of Proceedings, Surface Transportation Board Department of Transportation 395 E. Street S.W. Washington, DC 20423 Nearest Packers and Stockyards Administration area supervisor Associate Deputy Administrator for Capital Access United States Small Business Administration 403 Third Street, SW, 8th Floor Washington, DC 20416 Securities and Exchange Commission 100 F St NE Washington, DC 20416 Farm Credit Administration 1501 Farm Credit Drive Mclean, VA 22102-5090 FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center FCRA Washington, DC 20580 (877) 382-4357      PAGE 2 of  NUMPAGES 4 SAMPLE DISCLOSURE AND AUTHORIZATION: As the employer or user of consumer reports, it is your responsibility to ensure compliance with the FCRA and all relevant federal, state and local laws governing this area. (If you are located in California or Colorado and obtain credit reports separate forms apply). 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