DISCLOSURE
FOR BACKGROUND CHECK
Big Brothers Big Sisters of
Puget Sound
“BBBSPS”) will procure a consumer
report and/or investigative
consumer report (as defined under
the Fair Credit Reporting Act) on you in connection with your application for employment, or engagement as a volunteer
or independent contractor. These background reports may be obtained
at any time
after receipt of your authorization and, if you are hired or engaged
by the BBBSPS, throughout your
employment, engagement or contract
period.
TalentWise Solutions LLC (“TalentWise”), a consumer
reporting agency, will obtain the report for the BBBSPS. Further information regarding TalentWise, including its privacy policy,
may be found online at
www.TalentWise.com. TalentWise is located
at 19800 North Creek Parkway,
Suite 200, Bothell, WA 98011, and can be reached at (866) 338-6739.
The background report may contain
information bearing on your character, general reputation, personal
characteristics, and/or mode of living.
The
information that may be included
in your
report include: social
security number trace,
criminal conviction records, public
court or other government
agency records, driving records (where
driving is a required part
of
the job or engagement),
educational records checks, verification
of employment positions
held, personal and professional references
checks, and licensing and
certification checks. The information contained in the report will
be
obtained from private
and/or public record
sources, including sources identified
by you in your
job application or through interviews or correspondence with your past or present
coworkers, neighbors, friends,
associates, current or former
employers, educational institutions or other acquaintances.
You have the right, upon written request made within
a reasonable time after
receipt of this notice, to request
disclosure of the nature
and scope of any investigative consumer report obtained
by
BBBSPS.
AUTHORIZATION
I have carefully read and understand this disclosure and authorization form and I have received
a copy of the “Summary
of Your Rights Under the Fair Credit Reporting Act” provided with this form. I have had the opportunity
to review my rights. By my
signature below, I consent
to
the preparation of background reports by TalentWise, and to the release of such reports
to the BBBSPS and its designated representatives
for the purpose of assisting
the BBBSPS in making
a determination as to my eligibility
for
employment, promotion, retention, engagement as a volunteer or independent contractor, or for other lawful purposes.
I understand that, to the extent allowed by law, information contained in my job or volunteer
application, or otherwise
disclosed to the
BBBSPS by me before or during my employment, while volunteering or contracting, if any, may be utilized for the purpose of obtaining such consumer reports and/or
investigative consumer reports
about me. I understand that nothing herein shall be
construed as an offer of employment, service as a volunteer or offer to engage an independent contractor.
I hereby authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts (federal/state/local), motor vehicle record agencies, my past or present employers, the military,
and other individuals or sources
to furnish any and all information on me that is requested by the consumer
reporting agency.
By my signature (including electronic) below, I certify
the information provided
on and in connection with this form is true, accurate,
and complete. I agree that this form in original, faxed, photocopied or electronic form will be valid for any background reports that may be requested
by or on behalf of the BBBSPS.
This information
is being collected to conduct
the background screen on
you. It will not be
used for any other purpose.