DISCLOSURE and AUTHORIZATION TO OBTAIN INFORMATION
In connection with my suitability for employment with the University of Georgia Athletic Association, (herein “Client”) or if employed, I understand that prior to or at any time after my employment commences a consumer report may be requested for employment purposes from Priority Research, lnc., (herein: “Priority Research”) from public records including; but not limited to, Social Security number, motor vehicle operation history/driving records, workers’ compensation information and criminal history to the extent permitted by law from various local, state, and federal agencies. Further, I understand that an Employment Credit Report may be requested. Finally, I understand that an Investigative Consumer Report may be requested and, as required under §606(a)(1) of the Federal Fair Credit Reporting Act (FCRA), IS U.S.C.§1681 et seq.,I understand that this Report will include information as to my character, general reputation, personal characteristics, mode of living, work habits, performance, experience, along with reasons for termination of past employment, whichever are applicable, obtained through personal interviews with associates who have knowledge concerning such items of information.
I VOLUNTARILY AND KNOWINGLY AUTHORIZE ANY PRESENT OR PAST EMPLOYER OR SUPERVISOR, COLLEGE OR UNIVERSITY OR OTHER INSTITUTION OF LEARNING, ADMINISTRATOR, LAW ENFORCEMENT AGENCY, STATE AGENCY, LOCAL AGENCY, FEDERAL AGENCY, CREDIT BUREAU, PRIVATE BUSINESS, MILITARY BRANCH OR THE NATIONAL PERSONNEL RECORDS CENTER, PERSONAL REFERENCE, AND/OR OTHER PERSONS TO GIVE RECORDS OR INFORMATION THEY MAY HAVE CONCERNING MY CRIMINAL HISTORY, MOTOR VEHICLE HISTORY/DRIVING HISTORY, SOCIAL SECURITY NUMBER, EARNINGS HISTORY, CHARACTER, AND EMPLOYMENT (INCLUDING REASONS FOR TERMINATION), CREDIT HISTORY, CREDIT CAPACITY, OR CREDIT STANDING OR ANY OTHER INFORMATION REQUESTED BY PRIORITY RESEARCH DEEMED PERTINENT TO MY EMPLOYMENT.
In accordance with the FCRA and applicable state laws, I understand that I have the right to request a complete and accurate disclosure of the nature and scope of the investigation requested. Further, I am entitled to know if employment is denied because of information obtained by my prospective employer form a Reporting Agency. If so, I will be so advised in writing and be given the name, address and toll free number of the agency, a statement that the action was based in whole or in part on information contained in the Report, and written notice that I have the right (i) if I request, to obtain within sixty days a free copy of the Report from the Reporting Agency (under no circumstances shall such cost exceed the actual costs of duplication), and from any other Consumer Reporting Agency which compiles and maintains files on consumers on a nationwide basis; and, (ii) to dispute the accuracy or completeness of any information in a consumer report furnished by the Reporting Agency. I understand that upon my request with reasonable notice and after furnishing proper identification, Priority Research’s trained personnel will provide me with investigative information in my file during normal business hours in person or upon written request, by certified mail to a specified addressee, or telephone as permitted by law. Further, I understand that should I wish to review my file in person, I am permitted to be accompanied by one other person of my choosing who shall furnish reasonable identification and if requested, Priority Research will provide a written explanation of any coded information contained in my file. I understand that Priority Research is a Consumer Reporting Agency and it is Priority Research’s policy to not be involved in or make hiring decisions or recommendation.
Priority Research’s private policy limits the information it provides to the client named herein, however I hereby authorize the client to share such information with parties in interest who have a “need to know” such information to protect them and their employees. Priority Research does not sell or otherwise provide any of the information found in its background investigations to any other party other than the client.
I understand that any consumer report or investigative consumer report requested will be used strictly for employment purposes as defined under §603(h) and authorized under §604(a)(3)(B) of the Fair Credit Reporting Act, as a report to be used for the purpose of evaluation for employment, promotion, reassignment or retention as an employee. I further understand and consent to the furnishing of workers’ compensation information, after a conditional job offer, which may include my medical information including any and all injuries pursuant to state law and in compliance with the Federal Americans with Disabilities Act. In addition, I understand that any offer of employment, promotion, reassignment or retention will be conditional upon the receipt of satisfactory information as required by the subscriber, and that to be considered for employment, promotion, reassignment or retention, I must authorize the procurement of such report(s). A photographic or faxed copy of this form shall be as valid as the original.
