Backtrack Background Information Form – Fill Out and Use This PDF

8850 Tyler Blvd., Mentor, OH 44060	Phone (440) 205-8280 Fax (440) 205-8355
Visit our website at: www.backtracker.com	or email us at: btsearches@backtracker.com

BACKGROUND INFORMATION FORM FOR BACKGROUND CHECK

BackTrack, Inc. is an employment screening company that conducts background checks on prospective employees/employees for our clients as part of their standard hiring procedure. In order to perform this check, we need you to provide the following information. Please be sure to fill out this form completely and legibly.

APPLICANT INFORMATION (please print clearly & accurately)

Position Applying For:

Expected Salary:

Last Name

First Name

Middle Name

Maiden Name

Any Other Name(s) Used

Phone (

)

Home Address

E-Mail Address

City

State

Zip

County

From Mth/Yr

To Mth/Yr

Social Security Number *

Date of Birth *

Military Branch of Service

*For background screening purposes only

Driver's License Number

State License was Issued

High School

City/State Location

Year Graduated

Full Name Diploma Issued Under

If GED received, in what State

City/State Location

Date Received

Name Used for GED

College

City/State Location

Year Graduated

Degree Rec’d:

Associate

Bachelor

Master

Other ______________________ Student ID Number:

Full Name Used

List Previous Addresses (to cover last 7 years)

Address

City/State

Zip

County

From Mth/Yr

To Mth/Yr

Address

City/State

Zip

County

From Mth/Yr

To Mth/Yr

Are you currently employed?

YES

NO

May we contact your CURRENT EMPLOYER now?

YES

NO ( If marked YES, we WILL contact. )

Please Initial

IMPORTANT: If you are currently employed and do NOT wish for your current employer to be contacted, please check NO on the above box.

NOTE: The absence of any of the above information could result in a delay in processing your background. If necessary, a representative from BackTrack, Inc. will contact you for additional information in order to expedite the background process. Thank you for your assistance.

---FOR CLIENT USE ONLY – DO NOT WRITE BELOW THIS LINE---

CLIENT INFORMATION	SERVICES REQUESTED						RUSH ORDER ($27 extra charge)
Name:		PACKAGE:
		Level I (employment, education, criminal search, credit or SSN search, driving)
Title:		Level II	(employment, criminal search, credit or SSN search, driving)
		Level III	(employment, education, criminal search)
E-Mail Address:		Level IV	(employment, criminal search, credit or SSN search)
		Level V (criminal and SSN search)
		Level VI	(employment, education, criminal search, credit or SSN search)
Company Name:
		(Above packages check here for 5 year emp. history____ check here for only 3 year___)
		Criminal History (county)							Federal District Search
Address:		Civil Litigation							Statewide Search (where available)
City/State/Zip:		CrimeTrack (Criminal Database and National Sex Offender Search)
		GlobalTrack (Patriot Act Search)
If Applicable, Division or Code #:		Credit Report
Phone Number:		Employment History		Education				Driving Record		SSN Search
Fax Number:		Workers' Comp.		Military				Credential	Bus/Personal Ref.

F12-1205

YOU MUST COMPLETE BOTH THE BACKGROUND INFORMATION FORM AND THE DISCLOSURE AND

AUTHORIZATION FOR BACKGROUND CHECK

8850 Tyler Blvd., Mentor, OH 44060	Phone (440) 205-8280 Fax (440) 205-8355
Visit our website at: www.backtracker.com	or email us at: btsearches@backtracker.com

DISCLOSURE AND AUTHORIZATION FOR BACKGROUND CHECK (page 2 of 2)

Have you ever been convicted of, plead guilty, no contest or nolo contendere, to a misdemeanor or felony?* You are not obligated to disclose sealed, annulled or expunged convictions or convictions pardoned by the governor. Please be aware that a criminal conviction will not necessarily be a bar to employment and will be considered as it relates to the job in question. Failure to honestly and completely answer this question (other than as described below) will result in discontinued consideration of the application or termination of employment. A conviction will not necessarily be a bar to employment. This information will only be used for job-related purposes consistent with applicable law and is only relevant in determining whether the conviction is related to the job for which you are applying. Factors such as age at the time of the offense(s), recentness of the offense(s), seriousness of the offense(s), nature of the violation(s), its relation, if any, to the job you are seeking, and rehabilitation will be taken into account. Failure to honestly answer these questions will result in discontinued consideration of your application or termination of employment.

*Do not report any conviction that has been sealed, expunged, statutorily eradicated, annulled impounded, erased, dismissed under the First Offender’s law, pardoned by the Governor or which state law allows you to lawfully deny as set forth below. You are also not required to disclose violations, infractions, petty misdemeanors or summary offenses.

YES	NO If YES, please indicate county and state where convicted.			Date convicted	/	/
County and state where convicted				Date convicted	/	/
County and state where convicted				Date convicted	/	/

*CALIFORNIA applicants/residents only: You need not disclose any referral to, and participation in, any pre-trial or post-trial diversion program, or any misdemeanor convictions for which probation has been successfully completed and discharged. Do not list any marijuana- related misdemeanor convictions over two-years old.

*CONNECTICUT applicants/residents only: You need not disclose any conviction record that has been erased pursuant to sections 46b- 146, 54-76o or 54-142a of the Connecticut General Statutes. Records subject to erasure under these sections are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that was dismissed or nolled, or a criminal charge for which the person was found not guilty or received an absolute pardoned conviction. Any person whose records were erased within the meaning of these three sections may consider such events to have never occurred and may so swear under oath.

*HAWAII applicants/residents only. DO NOT respond to this question until you have been given a conditional offer of employment.

*KENTUCKY applicants/residents only. You do not respond “Yes” as a result of any misdemeanor conviction where the date of conviction was more than five years ago.

*MASSACHUSETTS applicants/residents only. DO NOT answer this question during the initial application stage or prior to any interview. Massachusetts law prohibits employers from making inquiries regarding applicants’ criminal history information in an initial written application form. You may be required to provide some criminal history information later in the hiring process.

*PENNSYLVANIA applicants/residents only: DO NOT answer this question during the initial application state or prior to any interview. You may be required to provide some criminal history information later in the hiring process.

*WASHINGTON applicants/residents only. You may exclude convictions that occurred over ten years ago.

F12-1205

Signature				Date
Printed Name			Company Applying To

Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20006.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For

more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street, N.W., Washington, DC 20006.

You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment - or to take another adverse action against you - must tell you, and must give you the name, address, and phone number of the agency that provided the information.

You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

a person has taken adverse action against you because of information in your credit report;

you are the victim of identify theft and place a fraud alert in your file;

your file contains inaccurate information as a result of fraud;

you are on public assistance;

you are unemployed but expect to apply for employment within 60 days.

In addition, all consumers are entitled to one free disclosure every 12 months upon request from each

nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.

You have the right to ask for a credit score. Credit scores are numerical summaries of your credit- worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

Page 4 of 7 ( Applicant Copy )

You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.

Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.

You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 888-5-OPT-OUT (888-567-8688).

You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore.

Page 5 of 7 ( Applicant Copy )

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General Federal. For information about your federal rights, contact:

		TYPE OF BUSINESS:	CONTACT:
			a. Bureau of Consumer Financial Protection
	1.a. Banks, savings associations, and credit unions with		1700 G Street NW
			Washington, DC 20006
		total assets of over $10 billion and their affiliates.
	b.	Such affiliates that are not banks, savings associations, or	b. Federal Trade Commission: Consumer Response
			Center – FCRA
		credit unions also should list, in addition to the Bureau:
			Washington, DC 20580
			(877) 382-4357
			a. Office of the Comptroller of the Currency
	2.	To the extent not included in item 1 above:	Customer Assistance Group
			1301 McKinney Street, Suite 3450
	a.	National banks, federal savings associations, and federal	Houston, TX 77010-9050
		branches and federal agencies of foreign banks	b. Federal Reserve Consumer Help Center
	b.	State member banks, branches and agencies of foreign	PO Box 1200
			Minneapolis, MN 55480
		banks (other than federal branches, federal agencies, and
		insured state branches of foreign banks), commercial	c. FDIC Consumer Response Center
		lending companies owned or controlled by foreign banks,
			1100 Walnut Street, Box #11
		and organizations operating under section 25 or 25A of the
			Kansas City, MO 64106
		Federal Reserve Act
	c.	Nonmember Insured Banks, Insured State Branches of	d. National Credit Union Administration
			Office of Consumer Protection (OCP)
		Foreign Banks, and insured state savings associations
			Division of Consumer Compliance and Outreach
	d.	Federal Credit Unions	(DCCO)
			1775 Duke Street
			Alexandria, VA 22314
			Asst. General Counsel for Aviation Enforcement &
			Proceedings Consumer Protection Division
	3.	Air carriers	Department of Transportation
			1200 New Jersey Avenue SE
			Washington, DC 20590
			Office of Proceedings, Surface Transportation Board
	4.	Creditors Subject to Surface Transportation Board	Department of Transportation
			395 E Street SW
			Washington, DC 20423
	5.	Creditors Subject to Packers and Stockyards Act	Nearest Packers and Stockyards Administration area
			supervisor
			Associate Deputy Administrator for Capital Access
	6.	Small Business Investment Companies	United States Small Business Administration
			409 Third Street, SW, 8th Floor
			Washington, DC 20416
			Securities and Exchange Commission
	7.	Brokers and Dealers	100 F Street NE
			Washington, DC 20549
	8.	Federal Land Banks, Federal Land Bank Associations,	Farm Credit Administration
		Federal Intermediate Credit Banks, and Production Credit	1501 Farm Credit Drive
		Associations.	McLean, VA 22102-5090
			FTC Regional Office for region in which the creditor
	9.	Retailers, Finance Companies, and All Other Creditors Not	operates or Federal Trade Commission: Consumer
			Response Center – FCRA
		Listed Above
			Washington, DC 20580
			(877) 382-4357
		Page 6 of 7 ( Applicant Copy )

NOTICE REGARDING BACKGROUND INVESTIGATION

PURSUANT TO CALIFORNIA LAW

Employer (the “Company”) intends to obtain information about you from an investigative consumer reporting agency and/or a consumer credit reporting agency for employment purposes. Thus, you can expect to be the subject of “investigative consumer reports” and “consumer credit 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 obtaining a criminal record report, verifying references, work history, your social security number, your educational achievements, licensure, and certifications, your driving record, and other information about you, and interviewing people who are knowledgeable about you. The results of this report 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 Back Track, Inc., 8850 Tyler Boulevard, Mentor, OH 44060, 800-991-9694. The source of any credit report will be Back Track, Inc., 8850 Tyler Boulevard, Mentor, OH 44060, 800-991-9694.

The Company agrees to provide you with a copy of an investigative consumer report when required to do so under California law.

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 on 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.

•A summary of all information contained in the ICRA’s file on you that is required to be provided by the California Civil Code will be provided to you via telephone, if you have made a written request, with proper identification, for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to you.

•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.

“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.

Page 7 of 7 ( Applicant Copy )