ࡱ> NPM HbjbjcTcT 4H>>\C$0gooooJ$ T6]lJJll6ool:oolo0@ 0Plllllll66llllllllllllllll : USA BACKGROUNDS INCORPORATED Wytheville Community College Authorization and Disclosure I authorize USA Backgrounds Incorporated (USABI) to seek and obtain consumer reports/ investigative reports about me as defined in the Fair Credit Reporting Act(FCRA). These investigative reports may include, but are not limited to federal, state, and county criminal search, nationwide criminal index search, sex offender search, social security number trace, credit check, and DMV search. I understand that these records may be used for the eligibility and qualification of my employment. I hereby authorize, without any reservation, the full release of these records and information for USABI and/or its agents to conduct the searches and to release those results to Wytheville Community College. I also authorize the full release of the information described above, without any reservation, throughout any duration of my employment at Wytheville Community College. I also certify that all information provided below is correct to the best of my knowledge. I agree that a copy or facsimile of this authorization shall be as valid as the original. In addition, I release and discharge USABI, and all of its agents, any expenses, losses, damages, and liabilities for the investigative process. Upon request, USABI will supply a copy of my reports and my rights under the Fair Credit Reporting Act. Requests may be directed to: USA Backgrounds Incorporated, P.O. Box 64921, Virginia Beach, VA 23467-4921or by contacting us at 757.471.4677. FULL NAME  FORMTEXT        FORMTEXT        FORMTEXT       LAST FIRST MIDDLE OTHER NAMES USED (IN THE PAST 7 YRS) _ FORMTEXT       / FORMTEXT       / FORMTEXT       SSN #  FORMTEXT    - FORMTEXT   - FORMTEXT      D.O.B  FORMTEXT       DMV#  FORMTEXT       STATE  FORMTEXT VA M/d/yyyy CURRENT ADDRESS  FORMTEXT       PREVIOUS ADDRESS  FORMTEXT       List all of the cities (to include the state) you have lived in the past 7 years:  FORMTEXT       / FORMTEXT       / FORMTEXT       / FORMTEXT       / FORMTEXT       HOME PHONE # ( FORMTEXT    ) FORMTEXT       CELL PHONE # ( FORMTEXT    ) FORMTEXT        FORMTEXT       Print Name ______________________________________ ____________________ Signature Date For Office Use Only CHECK ALL THAT ARE TO BE ORDERED: FAX TO 757.222.8400 Federal Crim.  FORMCHECKBOX  Nationwide  FORMCHECKBOX  Statewide  FORMCHECKBOX  Sex Off.  FORMCHECKBOX  SSN Trace  FORMCHECKBOX  Credit  FORMCHECKBOX  DMV Search  FORMCHECKBOX  Authorized by:_________________________________________________ Date______________ FAIR CREDIT REPORTING ACT (FCRA) SUMMARY You must be told if information in your file has been used against you. Anyone who uses information from a Credit Reporting Agency (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. 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 a copy of your file within 60 days of receiving notice of the action. You also are entitled to one free report every twelve months upon request. 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 finding to the CRA. (The source also 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. 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. 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 report that 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 more than seven years old: ten years for bankruptcies. 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, landlord, or other business. XY 246@BDFZ\^hjlnܹjTj*jth@+h>*CJU^JaJ/jh@+h>*CJU^JaJmHnHu*jh@+h>*CJU^JaJ$jh@+h>*CJU^JaJh@+h>*CJ^JaJh@+hCJ^JaJh@+h!=^Jh@+hbCJ^JaJh@+h|VjCJ^JaJh@+h|Vj5CJ ^JaJ h@+h|Vj^JXY  o p  $^gdJ 8xl$^gdJ^gd|Vj$a$gd|Vjgd|Vj $^a$gd|Vj6@(*,68:<>R׿ױnVHh@+h|Vj>*CJ^JaJ/jh@+hJ>*CJU^JaJmHnHu*j\h@+hJ>*CJU^JaJ$jh@+hJ>*CJU^JaJh@+h.,CJ^JaJh@+h|VjCJ^JaJh@+hJ>*CJ^JaJ/jh@+h>*CJU^JaJmHnHu$jh@+h>*CJU^JaJ*jh@+h>*CJU^JaJRTV`bdfh|~׿ױױ׿ױs`R<`*jh@+h>*CJU^JaJh@+h>*CJ^JaJ$jh@+h>*CJU^JaJh@+hICJ^JaJh@+h|VjCJ^JaJ*jDh@+hJ>*CJU^JaJh@+h|Vj>*CJ^JaJh@+hJ>*CJ^JaJ/jh@+hJ>*CJU^JaJmHnHu$jh@+hJ>*CJU^JaJ*jh@+hJ>*CJU^JaJ 468BDFPRfhjtvԹԹԀԹjԀԹT*jh@+h>*CJU^JaJ*j&h@+h>*CJU^JaJh@+hCJ^JaJ*jh@+h>*CJU^JaJ*j2h@+h>*CJU^JaJh@+h>*CJ^JaJh@+h|VjCJ^JaJ$jh@+h>*CJU^JaJ/jh@+h>*CJU^JaJmHnHu vx8:BDXZ\fhjůӛӍ怍mWm?m怍/jh@+hI>*CJU^JaJmHnHu*jh@+hI>*CJU^JaJ$jh@+hI>*CJU^JaJh@+hICJ^JaJh@+hI>*CJ^JaJ&h@+h>*CJ^JaJmHnHu*j"h@+h>*CJU^JaJh@+h>*CJ^JaJ$jh@+h>*CJU^JaJh@+h|VjCJ^JaJh@+hCJ^JaJlnfhBDF^`lmno ^gd@+ x4<%%^gdG4 %^gdI^gd|Vj \ 4^gdIhjnpߤ߁s]s*jh@+hI>*CJU^JaJh@+h|Vj>*CJ^JaJ*jh@+hI>*CJU^JaJh@+h|VjCJ^JaJh@+hICJ^JaJ/jh@+hI>*CJU^JaJmHnHu*jh@+hI>*CJU^JaJh@+hI>*CJ^JaJ$jh@+hI>*CJU^JaJ,.0:<>׿ױlT>T*j`h@+hG4>*CJU^JaJ/jh@+hG4>*CJU^JaJmHnHu*jh@+hG4>*CJU^JaJh@+hG4>*CJ^JaJ$jh@+hG4>*CJU^JaJh@+h|Vj>*CJ^JaJh@+hI>*CJ^JaJ/jh@+hI>*CJU^JaJmHnHu$jh@+hI>*CJU^JaJ*jth@+hI>*CJU^JaJ>\^`bvxzدŗ؁ŗt^ŗ*j h@+hG4>*CJU^JaJh@+hG4CJ^JaJ*jR h@+hG4>*CJU^JaJ/jh@+hG4>*CJU^JaJmHnHu*jh@+hG4>*CJU^JaJ$jh@+hG4>*CJU^JaJh@+hG4>*CJ^JaJh@+h.,CJ^JaJh@+h|VjCJ^JaJ  246@BDF^ fkm׿ײ{cUGGGGh@+h|Vj5CJ^JaJh@+h|Vj>*CJ^JaJ/jh@+h@+>*CJU^JaJmHnHu*j h@+h@+>*CJU^JaJh@+h@+>*CJ^JaJ$jh@+h@+>*CJU^JaJh@+h|VjCJ^JaJ/jh@+hG4>*CJU^JaJmHnHu$jh@+hG4>*CJU^JaJ*jT h@+hG4>*CJU^JaJoars*+`X!Y!!v"w" 7$8$H$^gd!$7$8$H$^a$gd!^gd|Vj  %./=>?BMN\]^aijxyp\'j h@+h@+CJU^JaJ'j h@+h@+CJU^JaJ'j h@+h@+CJU^JaJ'j8 h@+h@+CJU^JaJ'j h@+h@+CJU^JaJh@+h|VjCJ^JaJ'jP h@+h@+CJU^JaJh@+h@+CJ^JaJ!jh@+h@+CJU^JaJ$yz|ar*`X!!v"" # ##:#####DrDZEE_GGGGGH԰ᣰᣰᣰᣔh@+htu#CJ^JaJUh@+h!CJ^JaJh@+h!5CJ\^JaJ'jh@+h@+CJU^JaJh@+h|VjCJ^JaJh@+h@+CJ^JaJ!jh@+h@+CJU^JaJ'w""##:###rDZE[EE_G`GGH 7$8$H$^gd@+ 7$8$H$^gd!Your consent is required for reports that are provided to employers, or reports that contain medical information. A CRA may not give out information about you to your employer, or prospective employer, without your written consent. A CRA may not report medical information about you to creditors, insurers, and employers without your permission. You may choose to exclude your name from CRA lists unsolicited credit insurance offers. Creditors and insurers may use file information as the basis for sending you unsolicited offers of credit insurance. Such offers must include a toll-free phone number for you to call if you want your name and address removed from future lists. If you call, you must be kept off the lists for two years. If you request, complete, and return the CRA form provided for this purpose, you must be taken off the lists indefinitely. You may seek damages from violators. If a CRA, a user or (in some cases) a provider if CRA data, violates the FCRA, you may sue them in state or federal court. 21h:p!/ =!"#@$@% tDText1tDText2tDText3tDText4tDText5tDText6zDText7###xDText8##|DText9####D Text10M/d/yyyyvDText11zDText12VAvDText13vDText14vDText15vDText16vDText17vDText18vDText19|DText20###DText21###-####|DText22###DText23###-####vDText24tDeCheck1tDeCheck2tDeCheck3tDeCheck4tDeCheck5tDeCheck6tDeCheck7j 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ OJPJQJ_HmH nH sH tH H`H bNormal ^CJ_HaJmH sH tH DA D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List PK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]  HRv>yHow"H  ".46BH *03?ES_ceqtv!-3JV\    0 < @ B N T g s w y   . > M ] i y FtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtG$G$G$G$G$G$G$8@0(  B S  ?Text1Text2Text3Text4Text5Text6Text7Text8Text9Text10Text11Text12Text13Text14Text15Text16Text17Text18Text19Text20Text21Text22Text23Text24Check1Check2Check3Check4Check5Check6Check7#7 4Ofv"K 1 B g y  . M i  !5I1Fdu4]  A U x  ? ^ z     / V f   % . B M a i |   Xtu#@+G4!=|Vji!bI.,J@ @ X X@XXXXX,@X@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial7.@ CalibriA BCambria Math"1hEfGf+2+2$@0d2HX $P|Vj*!xxwcuserShivaji SamantaOh+'0t  0 < HT\dlwcuser Background Check Request.dotShivaji Samanta3Microsoft Office Word@@f픗 @sܗ +՜.+,0 hp   Wytheville Community College2  Title  !"#$&'()*+,./0123456789:;<>?@ABCDFGHIJKLORoot Entry F QData %1Table-WordDocument4HSummaryInformation(=DocumentSummaryInformation8ECompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q