Acknowledgment and Authorization for Background Check Form - Volunteer

Please electronically sign this Acknowledgment and Authorization for Background Check Form

For questions or comments on this form, please call or e-mail us
214-382-2727 - support@ciaresearch.com

Employer Information
Employer ID: -
Employer Name:Eucharist Church
Employer Address 1:2 Townsend, #3-102
Employer Address 2:
Employer City:San Francisco
Employer State/Province:CA
Employer Zip/Postal Code:94107

Fill Out Personal Information
First Name*:
Middle Name:
Last Name*:
Maiden or Alias Names Used:
Date of Birth (mm/dd/yyyy) *:
Social Security Number *: - -
Phone Number*:
Address *:
City *:
State/Province *:
Zip/Postal Code *:
Driver's License (# and State): -
*Required solely for background screening purposes and will not be used as hiring criteria.

Notice and Acknowledgment  

Employer may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the 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, and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by Clear Investigative Advantage LLC, 2801 Network Blvd, Suite 101, Frisco, TX 75034, Tel: 888-242-2503 or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing Employer to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, 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 receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of 'consumer reports' and/or 'investigative consumer reports' at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Clear Investigative Advantage or another outside organization acting on behalf of Employer, and/or Employer itself. I agree that a facsimile ('fax') or photographic copy of this Authorization shall be as valid as the original.

New York applicants only: Upon request, you will be informed whether or not a consumer report was requested by the Employer, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. You have the right to inspect and receive a copy of any investigative consumer report requested by the Employer by contacting the consumer reporting agency identified above directly. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law.

New York City applicants only: You acknowledge and authorize the Employer to provide any notices required by federal, state or local law to you at the address(es) and/or email address(es) you provided to the Employer.

Washington State applicants only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW.

Applicants, Employees, or Volunteers in all states, including Minnesota, Oklahoma, and California:

E-Sign Document
To electronically submit this release form, type in your first and last name, your email address and today's date. Then draw your signature in the box below. If you are on a smart phone or tablet, use your finger to draw the signature. By submitting this release form, you are agreeing that all information submitted is valid and correct. The electronic transmittal of this document shall not affect the legal effect, validity or enforceability of this document.

Type your first and last name:
Type your email address:
Type today's date (mm/dd/yyyy):

Draw your signature below

Submit Form
Enter the word in the picture in the field below, then submit this form.