Applicant Complete the Following
In connection with my application for employment, I understand that Atwill Media, Inc. may obtain information about me for employment purposes from a third party consumer reporting agency. An investigative employment report may be requested that will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment. Thus, I may be subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records, verification of your education or employment history, or other background checks. You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you and disclosure of the nature and scope of any investigative consumer report and to request a copy of your report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained within regard to applicants for employment is an investigation into your education and/or employment history conducted by Asurint, Compliance Department, P.O. Box 14730, Cleveland, OH 44145, (800) 906-2034, www.asuriant.com/Compliance.aspx, or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing Atwill Media, Inc to obtain from any outside organization all manner of consumer reports and investigative consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.
I acknowledge that a facsimile (FAX), electronic, or photographic copy of this Authorization shall be as valid as the original.
I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by Atwill Media, Inc. or its agent, to furnish the information described in Section 1.
It is our policy that we do not discriminate on the basis of race, national origin, creed, veteran status, religion, age, gender, sexual orientation or disability and to provide Equal Opportunity Employment. We appreciate your cooperation.
I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those items. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by Atwill Media, Inc at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university, information service bureau, employer, or insurance company to furnish any and all background information requested by Asurint, Compliance Department, P.O. Box 14730, Cleveland, OH 44145, (800) 906-2034, www.asurint.com/Compliance.aspx, another outside organization acting on behalf of Atwill Media, Inc, and/or the Atwill Media, Inc itself.
The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes. I hereby release the employer and agents and all persons, agencies, and entities providing information or reports about me from any and all liability arising out of the requests for or release of any of the above mentioned information or reports.
Other names you have used (separated by commas):
Social Security Number*(only digits, no dashes):
Date of Birth*(MM/DD/YYYY):
The follwing states require sex and race to obtain information: AL, AR, FL, GA, IA, IL, IN, MI, OR, SC, TX, WI
Driver's License Number*:
State Issuing License*:
Name as it appears on license*: