FCRA NOTICE AND ACKNOWLEDGMENT
IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING ACKNOWLEDGMENT
NOTICE REGARDING BACKGROUND INVESTIGATION
Provider OnBoarding (“the Company”) 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, but is not limited to:
employment and education verifications; insurance claim history, social security number verification; criminal and civil court records;
personal interviews; driving records and/or any other public records or any other information bearing on your character, general reputation,
personal characteristics and trustworthiness. 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.
The scope of this notice and authorization is all-encompassing, however, allowing the Company to obtain from any outside organization
all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout 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.
ACKNOWLEDGMENT AND AUTHORIZATION
I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION (above) and certify that I have read and understand the
document. 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 Universal Background
Screening, another outside organization acting on behalf of the Company, and/or the Company itself. I agree that a facsimile (“fax”)
or photographic copy of this Authorization shall be as valid as the original.
