Understanding the intricacies of legal documents is imperative for individuals navigating through employment processes, particularly when it involves background checks. The Form #459-413, a critical document used by the Oregon Public Employees Retirement System (PERS), serves this exact purpose by facilitating a thorough criminal history verification for potential employees. This form requires applicants to authorize PERS to conduct a criminal background check, a step that cannot be bypassed if appointment is to be finalized. It collects detailed personal information including prior names, social security number, address history, and more, to comprehensively assess an applicant's background. Additionally, the form aligns with the legal framework, including the Fair Credit Reporting Act and Title VII of the Civil Rights Act of 1964, to ensure the process respects applicants' rights against discrimination and provides avenues for contesting inaccuracies. The criminal history verification aims to evaluate the relevance of any conviction in the context of the position applied for while ensuring transparency and fairness in the employment process. This form exemplifies the balance between an organization's need for security and an individual's right to fair treatment, showcasing the procedural depth involved in sensitive areas such as background checks in employment settings.
| Question | Answer |
|---|---|
| Form Name | Form 459 413 |
| Form Length | 5 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 15 sec |
| Other names | FCRA, prescreened, IIM, background check oregon |
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR
Fax –
Authorization to Access Criminal History
Upon signing this form, I authorize the Oregon Public Employees Retirement System (PERS) to conduct a criminal background check. I understand that no appointment can be finalized until a criminal background check has been performed, and I agree to furnish the required information.
I understand that any information received by PERS as a result of this inquiry will be used only for its consideration and will be kept in confidence.
I understand that the existence of a criminal record in itself will not automatically preclude appointment. Title VII of the Civil Rights Act of 1964 protects against discrimination by an employer on the basis of an arrest record alone. The Bureau of Labor and Industries can be contacted for an explanation of any rights, if any, under the law.
I understand that I have the right to be told if the information in my file has been used to deny my application for employment; that I can find out what is in my file; and that I can dispute inaccurate information under the Fair Credit Reporting Act.
Please complete all of the following information:
Full name: _____________________________________________________________________________
Please list all previous names and corresponding dates: _________________________________________
______________________________________________________________________________________
Social Security number: _________________________________________________________________
Address: ______________________________________________________________________________
City: ____________________________________________ State: __________ Zip: _____________
Prior states resided in within the past five years: _______________________________________________
Drivers license number: ____________________ |
State of issue: _________________________________ |
Date of birth: ____________________________ |
Place of birth: _________________________________ |
Sex: ________ Race: _________ Height: _______ Weight: ______ Hair: ________ Eyes: _______
Signature: ____________________________________________________ |
Date: _________________ |
Reason for request: job applicant |
|
Authorized by: ________________________________________________ |
Date: _________________ |
Hiring Authority |
|
Form
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR
Fax -
Criminal History Verification Form
The purpose of the Criminal History Verification is to assist PERS in making informed decisions about candidate qualifications. In assessing the pertinence of a conviction record, the agency will consider such factors as the nature of the crime, when and where it occurred, and the duties of the position for which the application is made.
Warning: Falsely responding to any of the questions listed below may constitute a basis for disqualification of your application and/or termination of your employment.
1.Have you ever been convicted of a crime in the state of Oregon?
2.If convicted in Oregon, what was the crime for which you were convicted and the date of the crime?
3.Have you lived outside the state of Oregon any time during the five years prior to today? When and where?
4.Have you ever been convicted of a crime in a jurisdiction other than Oregon?
5.If convicted in a jurisdiction other than Oregon, when did the conviction occur, where did the con- viction occur, and what was the crime for which you were convicted?
Certification and signature: I understand that any oral or written statement that is false, fraudulent, or mis- leading that is contained in this form or made in the course of any related employment process, whether made by me or by others at my request, will result in rejection of my application, denial of employment, or dismissal if discovered after employment, and/or prosecution for a crime.
Print signature
Applicant’s signature |
Date |
Form
Para informacion en espanol, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
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/learn more or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
•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 identity 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
•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 removedor 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
•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.
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. For information about your federal rights, contact:
TYPE OF BUSINESS:
1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates.
b. Such affiliates that are not banks, savings associations, or credit also should list, in addition to the Bureau:
2. To the extent not included in item 1 above:
a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks
b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and insured state branches of foreign banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act
c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations
d. Federal Credit Unions
3.Air carriers
4.Creditors Subject to Surface Transportation Board
5.Creditors Subject to Packers and Stockyards Act
6.Small Business Investment Companies
7.Brokers and Dealers
8.Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations
9.Retailers, Finance Companies, and All Other Creditors Not Listed Above
CONTACT:
a. Bureau of consumer Financial Protection 1700 G Street NW
Washington, DC 20552
b. Federal Trade Commission: Consumer Response Center – FCRA Washington, DC 20580
(877)
a. Office of the Comptroller of the Currency Customer Assistance Group
1301 McKinney Street, Suite 3450 Houston, TX
b. Federal Reserve Consumer Help Center P.O. Box 1200
Minneapolis, MN 55480
c. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106
d. National Credit Union Administration Office of Consumer Protection (OCP)
Division of Consumer Compliance and Outreach (DCCO)
1775 Duke Street Alexandria, VA 22314
Asst. General Counsel for Aviation Enforcement & Proceedings Department of Transportation
400 Seventh Street SW
Washington, DC 20590
Office of Proceedings, Surface Transportation Board Department of Transportation
1925 K Street NW Washington, DC 20423
Nearest Packers and Stockyards Administration area supervisor
Associate Deputy Administrator for Capital Access United States Small Business Administration
403 Third Street, SW, 8th Floor Washington, DC 20416 Farm Credit Administration 1501 Farm Credit Drive Mclean, VA
FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center – FCRA Washington, DC 20580
(877)