Evolution Consulting
Background Check Authorization/Disclosure For Research Associates Program

I. I, , understand that in conjunction with my application for employment, or if I am currently employed, in consideration of my promotion or reassignment, that Research Associates Program may request and rely upon an investigative consumer report on me that is obtained from a consumer reporting agency, which may include information about one or more of the following items: my character, work habits, performance and experience, including employment eligibility for rehire, financial/credit history, criminal history records from any criminal justice agency in any or all federal, state, city and county jurisdictions, state Department of Motor Vehicle/Driver License Records to include traffic citations and registration, military records from the National Personnel Record Center, education records including transcripts and GPA, and requests for records and information from any individual, company, firm, corporation, present and/or past employers and public agencies (including the Social Security Administration and U.S. Citizenship and Immigration Services).

II. I hereby understand and authorize Research Associates Program to obtain and rely upon a consumer report generated on me after I have received a valid offer of employment or in consideration for promotion/reassignment. I acknowledge that to the extent an investigative consumer report is procured, I have the right to ask for a copy of the report; such request must be submitted to: Evolution Consulting, 49 Court Street, Suite 130, Binghamton, NY 13901 / info@evolutioncheck.com / phone: 1-607-773-2266 / website: www.evolutioncheck.com. The report will be furnished to me upon proper identification. I acknowledge that I have been informed of my rights under the Fair Credit Reporting Act as outlined by the Federal Trade Commission in this publication: https://www.consumer.ftc.gov/articles/pdf-0096-fair-credit-reporting-act.pdf

III. I fully understand that Research Associates Program and /or its vendor Evolution Consulting LLC, may be requesting information from public and private sources about any of the information noted in Section [I], and I freely give my consent for Research Associates Program and Evolution Consulting LLC. to do so.

IV. I agree that a photocopy or telephonic facsimile of this authorization shall be as valid as the original with the same authority as the original, and I specifically waive any written notice from any present or former employer who may provide information based upon this authorized request.

V. I hereby authorize, without reservation, any one contacted by Research Associates Program and /or its vendor Evolution Consulting LLC., to furnish the information described in Section [I]. Information may be released to Research Associates Program and /or its vendor Evolution Consulting LLC, by telephonic facsimile or email.

VI. I hereby authorize, without reservation, Research Associates Program and / or its vendor, Evolution Consulting LLC, to contact my former employer/employers for employment verification/references and eligibility for rehire information.

VII. I agree that this disclosure further serves as a request that any present or former employer, police department, educational or financial institution, or other person having personal knowledge about me, to furnish Evolution Consulting LLC any and all information in its possession regarding me in connection with my application for employment.

VIII. The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. By submitting this form, I acknowledge that I have not provided any genetic information when responding to a request for medical information. 'Genetic information,' as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

IX. California Employees: By submitting this form, I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. I acknowledge that I can receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by Evolution Consulting whenever I have a right to receive such a copy under California law. Link to document: Summary of your rights under CALIFORNIA CIVIL CODE §1786.22

X. New York Employees: By submitting this form, I acknowledge receipt of a copy of the New York Correction Law Article 23-A. Link to document: NEW YORK CORRECTION LAW ARTICLE 23-A

XI. Vermont Employees: By submitting this form, I acknowledge receipt of a copy of Section 2480e of the Vermont Fair Credit Reporting Statute ("VFCRA"). Link to document: VFCRA

XII. Minnesota Employees: By submitting this form, I acknowledge that I can receive a copy of an investigative consumer report or consumer report obtained on me at no charge by contacting Evolution Consulting as outlined in Section [II].

XIII. Oklahoma Employees: By submitting this form, I acknowledge that I can receive a copy of an investigative consumer report or consumer report obtained on me at no charge by contacting Evolution Consulting as outlined in Section [II].

XIV. Oregon Employees: By submitting this form, I acknowledge that information is available upon request regarding my rights under federal and Oregon laws regarding employment background checks.

XV. Washington State Employees: By submitting this form, I acknowledge receipt of A SUMMARY OF YOUR RIGHTS UNDER THE WASHINGTON FAIR CREDIT REPORTING ACT. Link to document: WFCRA

APPLICANT: COMPLETE THE FOLLOWING

  08/19/2017
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