MADDKENTUCKY

1. In connection with my employment or to volunteer with Mothers Against Drunk Driving, I understand that an investigative consumer report, limited to any criminal record that I may have, may be requested that will include information as to my character. I understand that as directed by company policy and consistent with the job described, you may be requesting information from public and private sources about my criminal record.

2. According to the Fair Credit Reporting Act (which applies to background checks pertaining to criminal records), I am entitled to know if any adverse decision is made concerning my activities with MADD because of information obtained by MADD from the consumer-reporting agency conducting my background check. If so, I will be notified and given the name and address of the agency or the source, which provided the information.

3. I acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as valid as the original. This release is valid for most federal, state and county agencies, for Minnesota applicants, including the Minnesota Department of Labor.

4. Minnesota and California applicants only. If you want a copy of the report(s) ordered, check this box. [ ]

5. I hereby authorize, without reservation, any law enforcement agency, institution, or information service bureau contacted by AVERT, INC. or its agent, to furnish the information described in Section 1. The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes. I hereby release the employer and agents and all person, agencies, and entities providing information or reports about me from any and all liability arising out of the requests for or release of any of the above-mentioned information or reports.

The following states require sex and race to obtain information: AL, AR, FL, GA, IA, IN, IA, OR, TX, WI.
Male [ ] Female [ ]
Asian [ ] Black [ ] Hispanic [ ] White [ ] Other [ ]

Disclosure to Employment/Volunteer Applicant
Regarding Procedure of a Consumer Report

In connection with your employment/volunteer application, we may procure a consumer report (limited to any criminal records that I may have) as part of the process of considering your candidacy as an employee/volunteer. In the event that information from the report is utilized in whole or in part making an adverse decision with regard your potential employment/volunteerism, before making the adverse decision, we will provide you with a copy of the consumer report and description in writing of your rights under the law.

Please be advised that you have the right to request, in writing within a reasonable time, that we make a complete an accurate disclosure of the nature and scope of the information requested. Such disclosure will be made to you within 5 days of the date on which we receive the request from you or within 5 days of the time the report was first requested.

The Fair Credit Reporting Act (which applies to background checks pertaining to criminal records) gives you specific rights in dealing with consumer reporting agencies. You will be given a summary of these rights together with this document.

By your signature below, you hereby authorize us to obtain a consumer report and/or an investigative report about you in order to consider you for employment or as a volunteer.

Applicant’s Name: ______________________________________________________________________________________
(Please Print)

Applicant’s Address: ______________________________________________________________________________________
(Street)

______________________________________________________________________________________
(City/State/Zip Code)

Applicant’s Signature: ______________________________________________________________________________________

Social Security Number: ______________________________________________________________________________________

Give one copy of this form to applicant with Summary of Rights. Retain a copy for your files.

A summary of Your Rights
Under the Fair Credit Reporting Act

The 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, at the Federal Trade Commission’s web site (http://www.ftc.gov). 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.

· You must be told if information in your file has been used against you. Anyone who uses information against you – such as denying an application for credit, insurance, or employment – must tell you, and give you name, address and phone number of the CRA that provided the consumer report.

· 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 and a list of anyone 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 are entitled to one free credit report every twelve months upon request if you certify that (1) you are unemployed and plan to seek employment with in 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.

· You can dispute inaccurate information with the CRA. If you tell the 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 any one who has recently received your report be notified of the change.

· 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 from 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.

· 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.

· Outdated information may not be reported. In most cases, a CRA may not report negative information that is not more than seven years old; ten years for bankruptcies.

· Access to your file is limited. A CRA may provide information about you to only people with a need recognized by the FRCA – usually to consider an application with a creditor, insurer, employer, landlord or to other business.

· 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.

· 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 number for you to call if you want your name and address removed from future lists. If you call, you must be kept of the list for two years. If you request, complete, and return the CRA form provided for this purpose, you must be taken of the lists indefinitely.

· You may seek damages from violators. If a CRA, a user or (in some cases) a provider of a CRA data, violates the FCRA, you may sue them in a state or federal court.
__________________________________________________
The FCRA gives several different federal agencies authority to enforce the FRCA:

For Questions or
Concerns Regarding:                                        Please Contact:
CRAs, creditors and others not                         Federal Trade Commission
listed below                                                      Bureau of Consumer Protection FRCA
                                                                        Washington, DC 20580    202-326-3761

National banks, federal Branches/ Office if the Comptroller of the Currency
agencies of foreign banks (word                       Compliance Management
“National or initials “N.A.”                             MS 6-6
appear in or after the banks’ name)                  Washington, DC 20219
800-452-3693

Federal Reserve system member                       Federal Reserve Board
banks (except national banks, and                     Consumer & Community Affairs
federal branches/agencies of                            Washington, DC 20551
foreign banks)                                                  202-452-3693

Savings associated federally                             Office of Thrift Supervision
chartered savings banks (word                         Consumer Programs
“Federal or initials “F.S.B.” appear                Washington, DC 20552
in federal institution’s name)                             800-842-6929

Federal credit unions (words                           National Credit Union Administration
“Federal Credit Union” appear in                    1775 Duke Street
institution’s name)                                           Alexandria, VA 22314
703-518-6360

Banks that are state-chartered or are not Federal Reserve System members

Federal Deposit Insurance Corporaton
Compliance & Consumer Affairs
Washington, DC 20429
800-934-FDIC

Air, surface or rail common carriers regulated by former Aeronautics Board or Interstate

Department of Civil Transportation
Office of Financial Commerce Commission
Washington, DC 20590
202-366-1306

Ativities subject to the Packers and Stockyards Act, 1921 Board or

Department of Agriculture
Office of Deputy Administrator – GIPSA
Washington, DC 205
202-720-7053

Release Authorization

Applicant Complete the Following

Notarize here