Sapphire Check – Disclosure and Authorization Form
DISCLOSURE REGARDINGBACKGROUND INVESTIGATION ON YOU
(“the Company”) may obtain “consumer reports” about youfrom a consumer reporting agency for employment purposes. A “consumer report”is a background screening report that may contain information regarding yourcriminal history, sex offender registry status, credit history, employment history,education history, driving history, professional licenses, and other informationabout you. It may bear upon your character, general reputation, personalcharacteristics, and/or mode of living.
ADDITIONAL NOTICE REGARDINGINVESTIGATIVE CONSUMER REPORTS ON YOU
(“the Company”) may also request an “investigativeconsumer report” on you from a consumer reporting agency.An “investigative consumer report” is a background screening report generatedthrough personal interviews with sources such as your neighbors, friends, orassociates.The consumer reporting agency that may prepare an “investigative consumerreport” 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 aninvestigation into your employment history. During such an investigation, SapphireCheck may ask questions about your employment history to certain knowledgeableindividuals and provide response information to the Company.Note: You have the right to request additional information regarding thenature and scope of any “investigative consumer report” ordered by theCompany on you. You may do so by contacting the Company.
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ADDITIONAL STATE LAW NOTICES
If you live in, work in, or are seeking work for (“the Company”) in WashingtonState, Massachusetts, New Jersey, New York, Minnesota, Oklahoma, or California, please note thefollowing information which we are required by state law to provide to you:
State of Washington applicants/employees only: If the Company requests an investigativeconsumer report (as defined by state law) from a consumer reporting agency, you have the rightto receive a complete and accurate disclosure of the nature and scope of the investigationrequested by the Company. You also have the right to request a written summary of your rightsand remedies under the Washington Fair Credit Reporting Act.Massachusetts applicants/employees only: If the Company requests an investigative consumerreport (as defined by state law) from a consumer reporting agency, you have the right to have acopy of the report upon request.New Jersey applicants/employees only: If the Company requests an investigative consumerreport (as defined by state law) from a consumer reporting agency, you have the right to have acopy of the report upon request.New York applicants/employees only: You have the right, upon written request, to be informedof whether or not an investigative consumer report (as defined by state law) was requested froma consumer reporting agency. If a report was requested, you will be provided with the name andaddress of the consumer reporting agency to whom the request was made. You may also inspectand receive a copy of the report by contacting Sapphire Check LLC, 117 Ditmas Avenue,Brooklyn, NY 11218, 888-993-4473. You are also now receiving a copy of Article 23-A of theNY Correction Law.Minnesota applicants/employees only: You have the right, upon written request, to receive acomplete and accurate disclosure of the nature and scope of the consumer report. A consumerreporting agency must make this disclosure within five (5) days of receipt of your request or ofthe Company’s request for the report, whichever is later. Please check this box if you wouldlike to receive a copy of a consumer report if one is obtained by the Company. Oklahoma applicants/employees only: Please check this box if you would like to receive a copyof a consumer report if one is obtained by the Company. California applicants/employees only: You are separately receiving a copy of the NoticeRegarding 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 investigativeconsumer reporting agency for employment purposes. Thus, you can expect to be the subject of“investigative consumer reports” obtained for employment purposes. Such reports may includeinformation about your character, general reputation, personal characteristics, and mode of living. Withrespect to any investigative consumer report from an investigative consumer reporting agency (“ICRA”),the Company may investigate the information contained in your employment application and otherbackground information about you, including but not limited to: your criminal history, sex offenderregistry status, driving history, education history, employment history, credit information, andprofessional licenses. The Company may also obtain comments from individuals who are knowledgeableabout you. These reports may be used as a factor in making employment decisions. The source of anyinvestigative 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 sentoutside the U.S. or its territories) may be found at https://www.sapphirecheck.com/.Under California Civil Code section 1786.22, you are entitled to find out from an ICRA what is in theICRA’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 thanthe 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 withrequests for certified mailings shall not be liable for disclosures to third parties caused bymishandling 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 providedby the California Civil Code) will be provided to you via telephone, if you have made a writtenrequest for telephone disclosure and the toll charge, if any, for the telephone call is prepaid by orcharged directly to you.“Proper Identification” includes documents such as a valid driver’s license, social security accountnumber, military identification card, and credit cards. Only if you cannot identify yourself with suchinformation may the ICRA require additional information concerning your employment and personal orfamily history in order to verify your identity.The ICRA will provide trained personnel to explain any information furnished to you and will provide awritten explanation of any coded information contained in files maintained on you. This writtenexplanation 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 reasonableidentification. An ICRA may require you to furnish a written statement granting permission to the ICRAto discuss your file in such a person’s presence.Please check this box if you would like to receive a copy of an investigativeconsumer report (as defined by relevant state law) at no charge if one is obtained bythe Company.
AUTHORIZATION REGARDING BACKGROUND INVESTIGATION
By signing below, I acknowledge receipt of the following separate documents (and certify that Ihave 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 ONYOU; 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 thehiring process and throughout my employment, if applicable.
Signature Date Printed 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: Full Current Address Additional Previous Address Within the Last 7 Years Additional Previous Address Within the Last 7 Years
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Your legal name
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Document Name: Sapphire Check – Disclosure and Authorization Form
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