Sapphire Check 2021 Disclosure and Authorization Form


DISCLOSURE REGARDING

BACKGROUND INVESTIGATION ON YOU

 (“the Company”) may obtain “consumer reports” about you from a consumer reporting agency for employment purposes.A “consumer report” is a background screening report that may contain information regarding your criminal history, sex offender registry status, credit history, employment history, education history, driving history, professional licenses, status on governmental exclusions, and/or sanctions lists, and other information about you. It may bear upon your character, general reputation, personal characteristics, and/or mode of living.

 

ADDITIONAL NOTICE REGARDING

INVESTIGATIVE CONSUMER REPORTS ON YOU

 

  (“the Company”) may also request an “investigative consumer report” on you from a consumer reporting agency.

 

An “investigative consumer report” is a background screening report generated through personal interviews with sources such as your neighbors, friends, or associates.

The consumer reporting agency that may prepare an “investigative consumer report” on you for the Company is Sapphire Check LLC, 117 Ditmas Avenue, Brooklyn, NY 11218, 888-993-4473. The information contained in an “investigative consumer report” may bear upon your character, general reputation, personal characteristics, and/or mode of living.

 

Please be advised that the nature and scope of the most common form of “investigative consumer report” that may be ordered by the Company is an investigation into your employment history. During such an investigation, Sapphire Check may ask questions about your employment history to certain knowledgeable individuals and provide response information to the Company.

 

Note: You have the right to request additional information regarding the nature and scope of any “investigative consumer report” ordered by the Company on you. You may do so by contacting the Company.

ADDITIONAL STATE LAW NOTICES

 

If you live in, work in, or are seeking work for (“the Company”) in Washington State, Massachusetts, New Jersey, New York, Minnesota, Oklahoma, or California, please note the following information which we are required by state law to provide to you:

State of Washington applicants/employees only: If the Company requests an investigative consumer report (as defined by state law) from a consumer reporting agency, you have the right to receive a complete and accurate disclosure of the nature and scope of the investigation requested by the Company. You also have the right to request a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

Massachusetts applicants/employees only:  If the Company requests an investigative consumer report (as defined by state law) from a consumer reporting agency, you have the right to have a copy of the report upon request.

New Jersey applicants/employees only: If the Company requests an investigative consumer report (as defined by state law) from a consumer reporting agency, you have the right to have a copy of the report upon request.

New York applicants/employees only: You have the right, upon written request, to be informed of whether or not an investigative consumer report (as defined by state law) was requested from a consumer reporting agency.  If a report was requested, you will be provided with the name and address of the consumer reporting agency to whom the request was made. You may also inspect and receive a copy of the report by contactingSapphire Check LLC, 117 Ditmas Avenue, Brooklyn, NY 11218, 888-993-4473. You are also now receiving a copy of Article 23-A of the NY Correction Law.

Minnesota applicants/employees only: You have the right, upon written request, to receive a complete and accurate disclosure of the nature and scope of the consumer report.  A consumer reporting agency must make this disclosure within five (5) days of receipt of your request or of the Company’s request for the report, whichever is later.  Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company.  o

Oklahoma applicants/employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company.o

California applicants/employees only: You are separately receiving a copy of the Notice Regarding Background Investigation Pursuant To California Law.

 

NOTICE REGARDING BACKGROUND INVESTIGATION

PURSUANT TO CALIFORNIA LAW

(For California Applicants and Employees Only)

  (“the Company”) intends to obtain information about you from an investigative consumer reporting agency for employment purposes.Thus, you can expect to be the subject of “investigative consumer reports” obtained for employment purposes. Such reports may include information about your character, general reputation, personal characteristics, and mode of living. With respect to any investigative consumer report from an investigative consumer reporting agency (“ICRA”), the Company may investigate the information contained in your employment application and other background information about you, including but not limited to: your criminal history, sex offender registry status, driving history, education history, employment history, credit information, professional licenses, and status on governmental exclusions and/or sanctions lists. The Company may also obtain comments from individuals who are knowledgeable about you. These reports may be used as a factor in making employment decisions. The source of any investigative consumer report (as that term is defined under California law) will be sapphire Check LLC, 117 Ditmas Avenue, Brooklyn, NY 11218, 888-993-4473. Information regarding Sapphire Check’sprivacy practices (including information about whether any consumer personal information will be sent outside the U.S. or its territories) may be found athttps://www.sapphirecheck.com/.

 

Under California Civil Code section 1786.22, you are entitled to find out from an ICRA what is in the ICRA’s file on you with proper identification, as follows:

  • In-person, by visual inspection of your file during normal business hours and upon reasonable notice. You also may request a copy of the information in person. The ICRA may not charge you more than the actual copying costs for providing you with a copy of your file.
  • By requesting a copy be sent to a specified addressee by certified mail.ICRAs complying with requests for certified mailings shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the ICRAs.
  • A summary of all information contained in the ICRA’s file on you (which is required to be provided by the California Civil Code) will be provided to you via telephone, if you have made a written request for telephone disclosure and the toll charge, if any, for the telephone call is prepaid by or charged directly to you.

“Proper Identification” includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. Only if you cannot identify yourself with such information may the ICRA require additional information concerning your employment and personal or family history in order to verify your identity.

The ICRA will provide trained personnel to explain any information furnished to you and will provide a written explanation of any coded information contained in files maintained on you. This written explanation will be provided whenever a file is provided to you for visual inspection.

You may be accompanied by one other person of your choosing, who must furnish reasonable identification. An ICRA may require you to furnish a written statement granting permission to the ICRA to discuss your file in such person’s presence.

 

Please check this box if you would like to receive a copy of an investigative consumer report (as defined by relevant state law) at no charge if one is obtained by the Company.o

AUTHORIZATION REGARDING BACKGROUND INVESTIGATION

By signing below, I acknowledge receipt of the following separate documents (and certify that I have read and understood them):

  • DISCLOSURE REGARDING BACKGROUND INVESTIGATION ON YOU;
  • A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT;
  • ADDITIONAL NOTICE REGARDING INVESTIGATIVE CONSUMER REPORTS ON YOU;
  • ADDITIONAL STATE LAW NOTICES.

 

By signing below, I also authorize to obtain “consumer reports” and “investigative consumer reports” about me for employment purposes at any time during the hiring process and throughout my employment, if applicable.

Signature:                                                                                                        Date:

 

Printed Name:

 

PERSONAL INFORMATION NEEDED FOR BACKGROUND CHECK

Please supply the following information to facilitate a background check on you.

Full Name (First, middle, last):   

Social Security Number:                     

Date of Birth:

Driver License No.:  

State Issued:  

Email: Employer’s Email:  

Full Current Address

Additional Previous Address Within the Last 7 Years

Additional Previous Address Within the Last 7 Years

Leave this empty:

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Signed by Sapphire check
Signed On: August 12, 2021

Signature Certificate
Document name: Sapphire Check 2021 Disclosure and Authorization Form
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August 12, 2021 8:38 am EDTSapphire Check 2021 Disclosure and Authorization Form Uploaded by Sapphire check - support@sapphirecheck.com IP 223.225.168.218