DISCLOSURE AND AUTHORIZATION

IMPORTANT - PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION
DISCLOSURE REGARDING BACKGROUND INVESTIGATION

Complete form below and click submit at bottom

Concord Youth Baseball League may obtain information about you for employment purposes from a third party consumer reporting agency. 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, which can involve professional interviews with current and past employers. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records ("driving records"), verification of your education or employment history, or other background checks. Credit history will only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying. 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 obtained with regard to applicants for employment is an investigation into your education, employment history, and criminal background check. The scope of this notice and authorization is all-encompassing, thereby allowing the Company to obtain from any outside organization all manner of consumer reports and investigative consumer reports.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt and review of this DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT (provided on next page) and certify that I have read and understand both documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" by the Concord Youth Baseball League at any time after receipt of this authorization. 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 Carey Consultants, another outside organization acting on behalf of the Concord Youth Baseball League, and/or the Concord Youth Baseball League itself. I agree that a facsimile ("fax"), electronic or photographic copy of this Authorization shall be as valid as the original. Further, I hereby release CONCORD YOUTH BASEBALL LEAGUE and any outside organization acting on behalf of the Concord Youth Baseball League, of any liability and responsibility in securing and compiling this background investigation and utilizing the information to assist them in making a hiring decision.

I UNDERSTAND FURTHER THAT ALTHOUGH THIS IS A BACKGROUND CHECKING FORM AND NOT AN EMPLOYMENT APPLICATION, FALSIFYING ANY INFORMATION ON THIS FORM CAN LEAD TO MY IMMEDIATE DISMISSAL OR DISCONTINUATION OF MY CANDIDACY FOR ANY POSITION, CONTRACTING ASSIGNMENT, PROMOTION OR TRANSFER.

Digital Signature Release
A value is required.    Today's Date: A value is required.
Type Full Name - Equivalent to handwritten signature
(required)



Section I: Candidate DATA
Last name
A value is required. (required)
First name
 A value is required. (required)
Middle Int
Date of Birth
 A value is required. (required)
Email Address
A value is required.  (required)
Social Security #
 A value is required. (required)
Alias Please indicate any other last names used & years they were utilized:
Street address
A value is required.
City
 A value is required. (required)
State/Zip
A value is required. (required)
Home/cell Phone
A value is required. (required)
Have you been terminated from any place of employment within the past 7 years?
 (required)
Please make a selection.
If yes, indicated place of employment, cause for
discharge & month/year this termination took place:
Please list addresses for the past 10 years:
1.
2.
3.


Section III: Driver's Information
Driver's License #
 A value is required. (required)
State issued
 A value is required. (required)
Has your license ever been revoked or suspended?
(required)
Please make a selection.

If yes, explain dates & Circumstances:

If you do not have a driver’s license, please explain why not:
Have you ever been convicted of a crime other than a minor traffic violation?
Yes     No
If yes, please explain, giving dates, locations & circumstances

(Empty Required Fields will display in RED)
By clicking the "Submit" you consent to terms stated above.

You will now be redirected to read the Fair Credit Reporting Act
(Please complete and submit to finish application)