Untitled Document

Untitled Document

1745 W. Grand Avenue, Haysville KS 67060

AUTHORIZATION FOR RELEASE OF INFORMATION

This authorization or photocopy hereof authorizes The National Screening Bureau or its representatives to fully incvestigate, in the manner it deems

appropriate, the information contained in my application.

This document also authorizes all individuals, partnerships, corporations or other entities to release to The National Screening Bureau or its authoirzed

representatives, any and all information, records, or documents whatsoever deemed by The National Screening Bureau of Wichita, Kansas or its

representatives to be necessary to complete its investigation on my application. Said information or documents may concern but are not necessarily limited

to character, ability, education background, general reputation, criminal conviction record, civil litigation, driving record, and former employment history

including the reasons for the termination.

All individuals or entities presented with authorization by The National Screening Bureau or its representatives are expressly authorized to permit The

National Screening Bureau or irs representatives to obtain copies of any and all documents or records they request and to surrender possion of such

documents to them for copying.

The Fair Credit Reporting Act gives you specific rights in dealing with consumer reporting agencies. A summary of these right has been plaved on the back

of this sheet.

Please complete the following and submit with your application and/or resume.

Date

______________________________________________

Print Full Name (Including Middle Initial):

______________________________________________

Social Security Number:

______________________________________________

Maiden Name (or Alias):

______________________________________________

May we contact your present employer?

Yes

Applicant's Signature:

______________________________________________

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the files of every "consumer

reporting agency" (CRA). Most CRAs are credit bureaus that gather and sell information about you such as if you pay your bills on time or have filed

bankruptcy to creditors, employers, landlords, and other businesses. You can find the complete text of the FCRA, 15 U.S.C. §§1681-1681u. The FCRA gives

you specific rights, as outlined below. You may have additional rights under state law. You may contact a state or local consumer protection agency or a

state attorney general to learn those rights. (A You must be told if information in your file has been used against you. Anyone who uses information from a

CRA to take action against you such as denying an application for credit, insurance, or employment must tell you, and give you the name, address, and

phone number of the CRA that provided the consumer report. (B) You can find out what is in your file. At your request, a CRA must give you the information

in your file, and a list of everyone who has requested it recently. There is no charge for the report if a person has taken action against you because of

information supplied by the CRA, if you request the report within 60 days of receiving notice of the action. You also are entitled to one free report every

twelve months upon request if you certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on welfare, or (3) your report

is inaccurate due to fraud. Otherwise, a CRA may charge you up to eight dollars. ( C ) You can dispute inaccurate information with the CRA. If you tell a CRA

that your file contains inaccurate information, the CRA must investigate the items (usually within 30 days) by presenting to its information source all relevant

evidence you submit, unless your dispute is frivolous. The source must review your evidence and report its findings to the CRA. (The source also must

advise national CRAs to which it has provided the data of any error.) The CRA must give you a written report of the investigation, and a copy of your report if

the investigation results in any change. If the CRA's investigation does not resolve the dispute, you may add a brief statement to your file. The CRA must

normally include a summary of your statement in future reports. If an item is deleted or a dispute statement is filed, you may ask that anyone who has

recently received your report be notified of the change. (D) Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate or

unverified information from its files, usually within 30 days after you dispute it. However, the CRA is not required to remove accurate data from your file

unless it is outdated (as described below) or cannot be verified. If your dispute results in any change to your report, the CRA cannot reinsert into your file a

disputed item unless the information source verifies its accuracy and completeness. In addition, the CRA must give you a written notice telling you it has

reinserted the item. The notice must include the name, address and phone number of the information source. (E) You can dispute inaccurate items with the

source of the information. If you tell anyone such as a creditor who reports to a CRA that you dispute an item, they may not then report the information to a

CRA without including a notice of your dispute. In addition, once you've notified the source of the error in writing, it may not continue to report the information

if it is, in fact, an error. (F) Outdated information may not be reported. In most cases, a CRA may not report negative information that is more than seven

years old; ten years for bankruptcies. (G Access to your file is limited. A CRA may provide information about you only to people with a need recognized by

the FCRA usually to consider an application with a creditor, insurer, employer, landlord, or other business. (H) Your consent is required for reports that are

provided to employers, or reports that contain medical information. A CRA may not give out information about you to your employer, or prospective

employer, without your written consent. A CRA may not report medical information about you to creditors, insurers, or employers without your permission. (I)

You may choose to exclude your name from CRA lists for unsolicited credit and insurance offers. Creditors and insurers may use file information as the basis

for sending you unsolicited offers of credit or insurance. Such offers must include a toll-free phone number for you to call if you want your name and address

removed from future lists. If you call, you must be kept off the lists for two years. If you request, complete, and return the CRA form provided for this purpose,

you must be taken off the lists indefinitely. ( J ) You may seek damages from violators. If a CRA, a user or (in some cases) a provider of CRA data, violates

the FCRA, you may sue them in state or federal court. The FCRA gives several different federal agencies authority to enforce the FCRA:

FOR QUESTIONS OR CONCERNS REGARDING

CRAs, creditors and others not listed below please contact

Federal Trade Commission

Consumer Response Center- FCRA

Washington, DC 20580 * 202-326-3761

National Credit Union Administration

1775 Duke Street

Alexandria, VA 22314 * 703-518-6360

Federal credit unions (words "Federal Credit Union"

appear in institution's name

Office of the Comptroller of the Currency

Compliance Management, Mail Stop 6-6

Washington, DC 20219 * 800-613-6743

Federal Deposit Insurance Corporation

Division of Compliance & Consumer Affairs

Washington, DC 20429 * 800-934-FDIC

State-chartered banks that are not members of the

Federal Reserve System

Federal Reserve Board

Division of Consumer & Community Affairs

Washington, DC 20551 * 202-452-3693

Federal Reserve System member banks (except

national banks, and federal branches/agencies of

foreign banks)

Department of Transportation

Office of Financial Management

Washington, DC 20590 * 202-366-1306

Air, surface, or rail common carriers regulated by

former Civil Aeronautics Board or Interstate

Commerce Commission

Office of Thrift Supervision

Consumer Programs

Washington D.C. 20552* 800- 842-6929

Savings associations and federally chartered savings

banks (word "Federal" or initials "F.S.B." appear in

federal institution's name)

Department of Agriculture

Office of Deputy Administrator-GIPSA

Washington, DC 20250 * 202-720-7051

Activities subject to the Packers and Stockyards Act,

1921