Free APPLICANT DISCLOSURE AND RELEASE FOR CONSUMER AND INVESTIGATIVE CONSUMER REPORTS - Indiana

APPLICANT DISCLOSURE AND RELEASE FOR CONSUMER AND INVESTIGATIVE CONSUMER REPORTS
State Form 51334 (R2 / 8-05 )

In connection with my application for employment with the State of Indiana, I understand that a consumer report and/or investigative consumer report, as defined by the Fair Credit Reporting Act (FCRA), may be obtained by an agent of the State of Indiana or from BARADA ASSOCIATES INC., its agents or employees, and I authorize all corporations, employers, co-workers, references, credit reporting agencies, educational institutions, licensing bodies, courts, law enforcement agencies, governmental agencies or departments, and military services to provide information about my background, including but not limited to driving records, court records, credit report, academic records, professional license record and employment information or records. I agree to release the aforesaid from any liability for collecting that information. I understand that an investigative consumer report is a special type of consumer report that is obtained through interviews and may contain information about my character, general reputation, personal characteristics, and/or mode of living. Upon my written request within a reasonable period of time, a complete disclosure of the nature and scope of that investigation will be made to me in writing within five days of the date on which the request was received. I further authorize the State of Indiana, if I am hired, to request a consumer report and/or investigative consumer report about me, for employment related purposes, at any time during the course of my employment to the extent allowed by law. I agree that this Disclosure and Release will be valid, now or in the future, in original, faxed, copied or electronic form. I acknowledge that I have received a copy of the "Summary of Your Rights Under the Fair Credit Reporting Act."

First Name Last Any other name(s) used Social Security #

Full Middle Suffix

Date of Birth

(MM/DD/ YYYY) I understand that my date of birth will be used solely for identification purposes.

The State is requesting your SSN under authority IC 4-1-8 to accomplish statutory purposes. Disclosure is mandatory and this form will not be processed without it.

Position Applied For Present Address City/State/Zip/County Telephone Number(s) Previous Cities/States of Residence During Last 7 Years

Driver's License #

State of Issuance

Signature of Applicant _______________________________________Date ________________________________ California, Minnesota, and Oklahoma residents only: Please initial here only if you are requesting a copy of the consumer report prepared on you ________.

Para Informacion en espanol, visite www.ftc.gov/credit o escribe a la FTC Consumer Response Center, Room 130-A 600 Pennsylvania Ave. N. W., Washington, D.C.

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.ftx.gov/credit or right to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580. · 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 you 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 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: · you are on public assistance: · you are unemployed but expect to apply for employment within 60 days. In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.ftc.gov/credit 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 fro free from the mortgage lender. 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.ftc.gov/credit 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.

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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 report 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 valid need for access. You must give your consent for the reports to be provided to employers. A consumer reporting agency may not give our information about you to your employer, or a potential employer, without written consent give to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.ftc.gov/credit. You may limit "prescreened" offers of a 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 1-888-5-OPTOUT (1-888-567-8688). 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.ftc.gov/credit.

States may enforce the FCRA, and many states have their own consumer reporting laws. In come 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 enforcers are:
TYPE OF BUSINESS:
Consumer reporting agencies, creditors, and others not listed below

CONTACT:

Federal Trade Commission Bureau of Consumer Protection ­ FCRA Washington, DC 20580 * 202-326-3650 National banks, federal branches/agencies of foreign banks (word Office of the Comptroller of the Currency "National" or initials "N.A." appear in or after bank's name) Compliance Management ­ Mail Stop 6-6 Washington, DC 20219 * 800-613-6743 Federal Reserve System member banks (except national banks and federal Federal Reserve Board banks and federal branches/agencies of foreign banks) Division of Consumer and Community Affairs Washington, DC 20551 * 202-452-3693 Savings associations and federally chartered savings banks (word Office of Thrift Supervision "Federal" or initials "F.S.B." appear in federal institution's name Consumer Programs Washington, DC 20552 * 800-842-6929 Federal credit union (words "Federal Credit Union" appear in institution's National Credit Union Administration name) 1775 Duke Street Alexandria, VA 22314 * 703-518-6360 Banks that are state-chartered, or are not Federal Reserve System members Federal Deposit Insurance Corporation Division of Compliance and Community Affairs Washington, DC 20429 * 800-934-FDIC Air, surface, or rail common carriers regulated by former Civil Department of Transportation Aeronautics Board of Interstate Commerce Commission Office of Financial Management Washington, DC 20590 * 202-366-1306 Activities subject to the Packers and Stockyards Act, 1921 Department of Agriculture Office of Deputy Administrator ­ GIPSA Washington, DC 20250 * 202-720-7051 The State of Indiana does not waive any immunities it might posses.