ࡱ> [ RTbjbjmm 4fbb2,T ***8b,|*x3h pz2222222$582i$$$2H23((($2($2((r1T#2hf2k%~22H30x32<9&<9#2<9#2l(!E22'x3$$$$<9 B : BACKGROUND CHECK DISCLOSURE & AUTHORIZATION Organization Name Douglas County School District Account DISCLOSURE The Douglas County School District and our agent Background Information Services, Inc. (BIS) located at 1800 30th Street, Ste 204, Boulder, CO 80310, (800) 433-6010, may order, prepare, report, obtain, and review consumer reports about you for employment purposes, including without limitation for the purposes of evaluating you for employment, promotion, reassignment and retention, at any time prior to or during your employment and without providing any additional notice. We may also order, prepare, report, obtain, and review investigative consumer reports through personal interviews with employers, supervisors, coworkers, clients, neighbors, friends, or associates, acquaintances, and others, as applicable, that may include without limitation, information about your character, general reputation, personal characteristics and mode of living, salary history, reason for termination, eligibility for rehire, and any disciplinary actions. You have the right to make a written request within a reasonable period of time for a free notice of the nature and scope of any investigative consumer report ordered. Such notice will be made in a writing mailed, or otherwise delivered to you not later than five days after the date such request was received or such report was first requested, whichever is the later. A copy of the FTC A Summary of Your Rights Under the FCRA is attached hereto. You may have additional rights under state law. NY & ME APPLICANTS ONLY: You have a right to know whether an investigative consumer report was requested and to inspect and receive a copy of any investigative consumer report by contacting BIS. By signing below you acknowledge receipt and understanding of the NEW YORK BACKGROUND CHECK NOTICE. APPLICANT INFORMATION (PLEASE PRINT OR TYPE) Last Name %First Name %Middle Name % % % % Social Security Number %Date of Birth (mm/dd/yy) %Other Names Used (maiden, married, AKA) %Dates Used % % % % / / % % Drivers License Number %State of Issue %Other Names Used (maiden/married/AKA) %Dates Used (yr  yr) % % % % % % ADDRESS HISTORY (PLEASE INCLUDE 7 YEARS OF HISTORY. Use reverse if necessary) 1%Current Street Address %City %State %Zip Code % % % % % % Date From (month/year) %Date To (month/year) %County (NOT Country) % % / % / % 2%Previous Street Address %City %State %Zip Code % % % % % % Date From (month/year) %Date To (month/year) %County (NOT Country) % % / % / % 3%Previous Street Address %City %State %Zip Code % % % % % % Date From (month/year) %Date To (month/year) %County (NOT Country) % % / % / % AUTHORIZATION I acknowledge receipt and understanding of this BACKGROUND CHECK DISCLOSURE and A SUMMARY OF YOUR RIGHTS UNDER THE FCRA. I agree that a copy of this Authorization is as valid as the original. I hereby authorize the Douglas County School District and its agent BIS to order, prepare, report, obtain, and review consumer reports and investigative consumer reports about me for employment purposes at any time prior to or during my employment and without giving me any additional notice. I authorize any and all persons, employers, supervisors, coworkers, schools, companies, corporations, organizations, courts, and governmental, law enforcement, military, driving record, licensing and certification agencies, and any other information source to provide all information requested to the organization above and BIS. I authorize any and all credit bureaus to provide my credit report to the organization above and BIS. %MN & OK APPLICANTS ONLY: Check box to receive a copy of any consumer report. %CA APPLICANTS ONLY: Check box to receive a copy of any consumer report/investigative consumer report. By signing below you acknowledge receipt and understanding of the CALIFORNIA BACKGROUND CHECK NOTICE. Signature Date / / Para informacion en espanol, visite  HYPERLINK "http://www.ftc.gov/credit " www.ftc.gov/credit o escribe a la FTC Consumer Response Center, Room 130-A 600 Pennsylvania Ave. N.W., Washington, D.C. 20580. 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  HYPERLINK "http://www.ftc.gov/credit " 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. 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 identify 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, 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  HYPERLINK "http://www.ftc.gov/credit " www.ftc.gov/credit 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.ftc.gov/credit" www.ftc.gov/credit 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 w.ftc HYPERLINK "http://www.ftc.gov/credit" www.ftc.gov/credit. 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). 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.ftc.gov/credit" www.ftc.gov/credit. 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. Federal enforcers are: TYPE OF BUSINESS:CONTACT:Consumer reporting agencies, creditors and others not listed belowFederal Trade Commission: Consumer Response Center - FCRA Washington, DC 20580 1- 877-382-4357National 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 800-613-6743Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks)Federal Reserve Board Division of Consumer & Community Affairs Washin+,-?@_dnqrs~% _ ` ./WXp<`XvpHJLPͮ웎zzqh5>*CJh.M56B*CJph h>*CJh56B*CJphh5B*CJph h5CJhCJOJQJh5CJH* h=1-CJ hCJ hCJh=1-5>*CJh5>*CJ h5CJ hCJ hCJ h5CJ,,-rs~_ ` ./WX,$d%d&d'd-D M NOPQ $]`a$$a$ $ $0*a$<`XvpL,$d%d&d'd-D M NOPQ#$d%d&d'dNOPQ,$d%d&d'd-DM NOPQPNl(>fj  '(127?@Ae˷ˢܜ܌tdhaKh56CJ^JaJhaKh>*CJ^JaJh4[h5>*h5>*CJ h>*CJ hCJhCJOJQJh5CJOJQJh=1-CJOJQJhCJOJQJhCJOJQJ h5CJ h5CJ hCJh5>*CJ hCJ h>*CJ'Nl(>f  #$ & 0` P@1$7$8$H$`a$#$d%d&d'dNOPQ,$d%d&d'd-DM NOPQ  ?AM!!m#n#$ & F$a$gdaK`d`` $]`a$ & 0` P@1$7$8$H$`efM ?!@!h!i!|!}!!!G"n##'孟v]I]9]vvvhaKh0J5CJ^JaJ'haKh5>*B*CJ^JaJph0jhaKh5>*B*CJU^JaJphhaKh5CJ^JaJhaKhCJ^JaJhaKh5CJ^JaJhaKhaK5CJ^JaJhaKh56CJ^JaJ"haKh0J56CJ^JaJ*haKh56>*B*CJ^JaJph3jhaKh56>*B*CJU^JaJph$$>%%%%/&0&_'`'))**++,,--L/M/0011{2|2 & F^ & F''-'.'A'B'`'')[)**@*A*S*T*U***+,,,-.//6/7/I/J/M//001!2=2>2e2f2x2y2{23333333V4X444I5K55PPPPPPPJQKQ蹫չ蹫蹫UhaKh5CJ^JaJhaKhCJ^JaJhaKh0JCJ^JaJ$haKh>*B*CJ^JaJph-jhaKh>*B*CJU^JaJphB|2333333)4W4okd$$Ifl0j' t04 lan$IfW4X4445(5=5J5 _$If$Ifokd$$Ifl0j' t04 lanJ5K55555PP$Ifokd$$Ifl0j' t04 langton, DC 20551 202-452-3693Savings 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 800-842-6929Federal credit unions (words "Federal Credit Union" appear in institution's name) National Credit Union Administration 1775 Duke Street Alexandria, VA 22314 703-519-4600State-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 1-877-275-3342Air, 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 202-366-1306Activities subject to the Packers and Stockyards Act, 1921 Department of Agriculture Office of Deputy Administrator - GIPSA Washington, DC 20250 202-720-7051       HYPERLINK "http://www.bisi.com/index.php"   3/2009 VERSION PPPPPPPP$Ifokd}$$Ifl0j' t04 lanPP6QJQKQqQQQQ$Ifokd$$Ifl0j' t04 lanKQQQQQRRRRVSXSSSSSSSSTTTTTT T T5T6T7T8T;TT?T@TOTPTQTRTʸƴƖ hCJ h5B* CJOJQJph hCJjAh=1-Uh=1-jwhUmHnHuhjLhUhgJ}jhgJ}U h4[hhaKh5CJ^JaJhaKhCJ^JaJ'QQQQQRPRrRR$Ifokd{$$Ifl0j' t04 lanRRRRR5SJSWS$Ifokd$$Ifl0j' t04 lanWSXSSSSSSSS$Ifokdy$$Ifl0j' t04 lanSSSSSTTTTTT T>T?T $0*`okd$$Ifl0j' t04 lan ?T@TOTPTQTRT`7$8$H$ $7$8$H$a$21h:paK/ =!"#$%Y }$$Ifn!vh#v:V l t054an}$$Ifn!vh#v:V l t054an}$$Ifn!vh#v:V l t054an}$$Ifn!vh#v:V l t054an}$$Ifn!vh#v:V l t054an}$$Ifn!vh#v:V l t054an}$$Ifn!vh#v:V l t054an}$$Ifn!vh#v:V l t054an}$$Ifn!vh#v:V l t054anY=Ddp   AJ?L Background Information Services, IncPicture 1Background Information Services, Inc.b;,{ӗ[G;Nn;,{ӗ[GPNG  IHDRd@sRGB pHYs+;cIDATx^|Sof4ni)PDAq DnQQ\|[`{@QDP-wΤiMۛ MG><}s;'IՀUm6j@ՀT9߃*n=*Qg^M,,f+vGAUMSV'hYSu-:dZ‰}*dSɯj J @˶$A3:FFz%}dL$2RLz6A$[v- :KJ"i1':j՛~3ww/TfDB :IЗJB2&dvx=zԷ}d)1Of|·薚U@Ѭu3מҽsNV銂*+]7ydLLKx5U$ 9)N(/|:tHNN6L6MoٲUV_~y]=Vh 7|j7hL.NZd ˤܴ6ٹif&[ .rժ]{Km7l.]t6:<.Kry,} ! 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