DocuSign Envelope ID: DD670824-2C8D-48A4-B214-E9E85F1AE9F9
DISCLOSURE REGARDING BACKGROUND INVESTIGATION
TotalMed Staffing/AWI Staffing (“the Company”) may obtain information about you from a third-party 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 information about your character, general reputation, personal
characteristics, and/or mode of living. These reports may contain information regarding your criminal history, social
security verification, motor vehicle records ("driving records"), verification of your education or employment history, or
other background checks.
You have the right, upon written request made within a reasonable time, to request whether a consumer report has
been run about you, and disclosure of the nature and scope of any investigative consumer report and to request a copy
of your report. Please be advised that the nature and scope of the most common form of investigative consumer report
are employment verifications and references, or personal references. If not done by a Company representative, these
searches will be conducted by one of the following companies:
• Universal Background Screening, Inc., Post Office Box 5920, Scottsdale, AZ 85261, 1-877-263-8033,
[Link].
• Sterling Infosystems, Inc. (“STERLING TALENT SOLUTIONS”), 1 State Street, New York, NY 10004, (877) 424-2457,
[Link]
The scope of this disclosure is all-encompassing, however, allowing the Company to obtain from any outside
organization all manner of consumer reports throughout the course of your employment to the extent permitted by law.
The information gathered by the Company and any consumer reports and/or investigative consumer reports may also
be communicated to other companies where you may be eligible to be staffed or employed based on your qualifications.
12/13/2017 | [Link] PM PST
____________________________________________________ ________________________________
Employee Signature Date
DocuSign Envelope ID: DD670824-2C8D-48A4-B214-E9E85F1AE9F9
Para información en español, visite [Link]/learnmore o escribe a la
Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
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 [Link]/learnmore or write
to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.
• 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 your 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 file
disclosure if:
• a person has taken adverse action against you because of information in your credit
report;
• you are the victim of identity theft and place a fraud alert in your file;
• your file contains inaccurate information as a result of fraud;
• you are on public assistance;
• you are unemployed but expect to apply for employment within 60 days.
In addition, all consumers are entitled to one free disclosure every 12 months upon request
from each nationwide credit bureau and from nationwide specialty consumer reporting
agencies. See [Link]/learnmore 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 for 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
[Link]/learnmore for an explanation of dispute procedures.
DocuSign Envelope ID: DD670824-2C8D-48A4-B214-E9E85F1AE9F9
• 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.
• 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 reporting 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 a valid need
for access.
• You must give your consent for reports to be provided to employers. A consumer
reporting agency may not give out information about you to your employer, or a potential
employer, without your written consent given to the employer. Written consent generally is
not required in the trucking industry. For more information, go to
[Link]/learnmore.
• You may limit “prescreened” offers of 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 [Link]/learnmore.
States may enforce the FCRA, and many states have their own consumer reporting laws. In
some 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. For information
about your federal rights, contact:
TYPE OF BUSINESS: CONTACT:
1.a. Banks, savings associations, and credit a. Consumer Financial Protection Bureau
unions with total assets of over $10 billion and 1700 G Street, N.W.
their affiliates Washington, DC 20552
b. Such affiliates that are not banks, savings b. Federal Trade Commission: Consumer
associations, or credit unions also should list, Response Center – FCRA
DocuSign Envelope ID: DD670824-2C8D-48A4-B214-E9E85F1AE9F9
in addition to the CFPB: Washington, DC 20580
(877) 382-4357
2. To the extent not included in item 1 above:
a. National banks, federal savings associations, a. Office of the Comptroller of the Currency
and federal branches and federal agencies of Customer Assistance Group
foreign banks 1301 McKinney Street, Suite 3450
Houston, TX 77010-9050
b. State member banks, branches and agencies
of foreign banks (other than federal branches, b. Federal Reserve Consumer Help Center
federal agencies, and Insured State Branches of P.O. Box. 1200
Foreign Banks), commercial lending Minneapolis, MN 55480
companies owned or controlled by foreign
banks, and organizations operating under
section 25 or 25A of the Federal Reserve Act
c. Nonmember Insured Banks, Insured State c. FDIC Consumer Response Center
Branches of Foreign Banks, and insured state 1100 Walnut Street, Box #11
savings associations Kansas City, MO 64106
d. Federal Credit Unions d. National Credit Union Administration
Office of Consumer Protection (OCP)
Division of Consumer Compliance and
Outreach (DCCO)
1775 Duke Street
Alexandria, VA 22314
3. Air carriers Asst. General Counsel for Aviation
Enforcement & Proceedings
Aviation Consumer Protection Division
Department of Transportation
1200 New Jersey Avenue, S.E.
Washington, DC 20590
4. Creditors Subject to the Surface Office of Proceedings, Surface Transportation
Transportation Board Board
Department of Transportation
395 E Street, S.W.
Washington, DC 20423
5. Creditors Subject to the Packers and Nearest Packers and Stockyards
Stockyards Act, 1921 Administration area supervisor
6. Small Business Investment Companies Associate Deputy Administrator for Capital
Access
United States Small Business Administration
409 Third Street, S.W., 8th Floor
Washington, DC 20416
7. Brokers and Dealers Securities and Exchange Commission
100 F Street, N.E.
DocuSign Envelope ID: DD670824-2C8D-48A4-B214-E9E85F1AE9F9
Washington, DC 20549
8. Federal Land Banks, Federal Land Bank Farm Credit Administration
Associations, Federal Intermediate Credit 1501 Farm Credit Drive
Banks, and Production Credit Associations McLean, VA 22102-5090
9. Retailers, Finance Companies, and All Other FTC Regional Office for region in which the
Creditors Not Listed Above creditor operates or Federal Trade
Commission: Consumer Response Center –
FCRA
Washington, DC 20580
(877) 382-4357
DocuSign Envelope ID: DD670824-2C8D-48A4-B214-E9E85F1AE9F9
AUTHORIZATION TO OBTAIN EMPLOYMENT BACKGROUND REPORT
I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A
SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both
of those documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" by
TotalMed Staffing (“the Company”) at any time after receipt of this authorization and throughout my employment, if
applicable and as permitted by law. 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 one of the following
companies and/or the Company itself:
• Universal Background Screening, Inc., Post Office Box 5920, Scottsdale, AZ 85261, 1-877-263-8033,
[Link].
• Sterling Infosystems, Inc. (“STERLING TALENT SOLUTIONS”), 1 State Street, New York, NY 10004, (877) 424-2457,
[Link]
I agree that a facsimile ("fax"), electronic or photographic copy of this Authorization shall be as valid as the original.
12/13/2017 | [Link] PM PST
____________________________________________________ ________________________________
Employee Signature Date
State Rights
New York applicants only: Upon request, you will be informed whether or not a consumer report was requested by the Company, and if such report was
requested, informed of the name and address of the consumer reporting agency that furnished the report. You have the right to inspect and receive a copy
of any investigative consumer report requested by the Company by contacting the consumer reporting agency identified above directly. By signing below,
you acknowledge receipt of Article 23-A of the New York Correction Law.
Washington State applicants only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies
under the Washington Fair Credit Reporting Act.
Minnesota and Oklahoma applicants only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the
Company.
California applicants or employees only: Under California Civil Code section 1786.22, you are entitled to find out what is in the CRA's file on you with
proper identification, as follows:
• In person, by visual inspection of your file during normal business hours and on reasonable notice. You also may request a copy of the information in
person. The CRA may not charge you more than the actual copying costs for providing you with a copy of your file.
• A summary of all information contained in the CRA file on you that is required to be provided by the California Civil Code will be provided to you via
telephone, if you have made a written request, with proper identification, for telephone disclosure, and the toll charge, if any, for the telephone call is
prepaid by or charged directly to you.
• By requesting a copy be sent to a specified addressee by certified mail. CRAs complying with requests for certified mailings shall not be liable for
disclosures to third parties caused by mishandling of mail after such mailings leave the CRAs
Proper Identification" includes documents such as a valid driver's license, social security account number, military identification card, and credit cards. Only
if you cannot identify yourself with such information may the CRA require additional information concerning your employment and personal or family
history in order to verify your identity. The CRA will provide trained personnel to explain any information furnished to you and will provide a written
explanation of any coded information contained in files maintained on you. This written explanation will be provided whenever a file is provided to you for
visual inspection. You may be accompanied by one other person of your choosing, who must furnish reasonable identification. A CRA may require you to
furnish a written statement granting permission to the CRA to discuss your file in such person's presence
Please check this box if you would like to receive a copy of an investigative consumer report at no charge if one is obtained by the Company whenever you
have a right to receive such a copy under California law.
DocuSign Envelope ID: DD670824-2C8D-48A4-B214-E9E85F1AE9F9
REQUIRED INFORMATION
Lourdes Amador
Name (Last, First, MI): _______________________________________________________________________________
Other name(s) in which you have been known by (including maiden name). If none please enter N/A:
Castro
_________________________________________________________________________________________________
347765703
7/3/1978
Social Security No: ___________________________________________ Date of Birth: _________________________
A53652078789 Illinois
Driver’s License No: __________________________________________ State of Issue: _________________________
Present address:
1627 Ridgeland Ave
Street Address: _____________________________________________________________________________________
Berwyn Illinois 60402
City: ___________________________________________ State: ___________________ Zip Code: __________________
Addresses within the past seven (7) years:
818 13th ave
1) _______________________________________________________________________________________________
2216 s 61st ave
2) _______________________________________________________________________________________________
3) _______________________________________________________________________________________________
4) _______________________________________________________________________________________________
5) _______________________________________________________________________________________________
6) _______________________________________________________________________________________________
7) _______________________________________________________________________________________________
I hereby certify that the above information is true and correct to the best of my knowledge. I understand that a false
information may disqualify me from employment opportunities.
12/13/2017 | [Link] PM PST
_________________________________________________________________________ __________________________________
Employee Signature Date
