Background Screening Notice Disclosure, and Authorization ...



BACKGROUND SCREENING NOTICE,

DISCLOSURE, AND AUTHORIZATION

• Complete all applicable sections of this form.

• Return the completed form to your Kelly representative as directed.

NOTICE AND DISCLOSURE

Kelly Services, Inc. (“Kelly”) may request, for lawful employment purposes, that background screens be conducted to verify any information I have provided in connection with my employment with Kelly, or a customer of Kelly, to determine my suitability for employment, retention, reassignment or to make other employment decisions that affect me.

Kelly may request consumer reports and/or investigative consumer reports (collectively “consumer reports”) in connection with my application for employment1 or at any time during my employment in accordance with all applicable laws. These reports may include information bearing on my character, general reputation, personal characteristics or mode of living. The nature and scope of the investigation conducted to compile the consumer report may include verification and inspection of any lawfully available records or information pertaining to your work history, education, criminal background, civil court related actions, driving history (including traffic-related offenses), credit or credit capacity, any other information available from any public or otherwise documented records, as well as written or oral information from any business, professional or personal associates or neighbors, including your co-workers and any references you listed on your application or resume.

Upon written request to Kelly, you have the right to be informed when a consumer report is obtained, the nature and scope of the inquiry, and the name and address of the consumer reporting agency2 providing the report. If Kelly is considering making an adverse employment decision that affects you based on the information provided in the consumer report, you will be notified before the decision is finalized.

AUTHORIZATION

By my signature below, I voluntarily authorize Kelly to obtain consumer reports about me and to consider such reports when making hiring, retention, reassignment or other employment decisions that affect me.3 I understand and agree that a consumer report may be obtained at any time, and any number of times, as Kelly in its sole discretion determines is necessary before, during or after my employment, until I revoke this authorization in writing. I understand that Kelly will notify me if a consumer reporting agency other than Verifications, Inc. is used to obtain a consumer report2. I also understand and agree that the results of the report may be shared with customers when necessary to determine my suitability for employment, retention, or reassignment. I further acknowledge receipt of “A Summary of Your Rights Under the Fair Credit Reporting Act.”

To the fullest extent permitted by law, I release Kelly, its employees, agents, successor and assigns, from any and all claims, actions or liability whatsoever that are in any way related to the procurement of a consumer report about me, or any subsequent investigation(s) of my background or personal history. I understand that this Authorization is not a contract for continued employment and does not alter the at-will nature of my employment or offered employment.

If you are currently employed, may we contact your employer to verify employment? Yes No

Branch instructions: If the applicant checks No above, do not select the current employer when completing the request for a background screen.

I have read this Background Screening Notice, Disclosure, and Authorization, I understand it, and I agree to its terms4.

                 

Full Legal Name (Printed) Last 4 digits of SSN Other Legal Names Used (e.g., maiden or alias) (Printed)

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Signature Date

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Electronic Signature* Date

|*If you are submitting this form electronically, type your name on the Electronic Signature line and check the box to the right | I agree. |

|next to “I agree.” This is your electronic signature. By electronically signing this form, you agree that you have reviewed this | |

|entire form and agree to all the terms contained in it. | |

1 Applicants/Employees in Hawaii: a background screening will only be conducted after an offer of employment.

2 Applicants/employees in California: The consumer reporting agency used to provide the report is:

Verifications, Inc., 11100 Wayzata Blvd #405, Minnetonka, MN 55305, 763-420-0600,

Name:      Address:      Phone:       Website:       

A subsequent notice will be sent for future consumer reports requested.

3 Applicants/employees in California, Minnesota, and Oklahoma:

By checking this box, I request a free copy of any consumer report from the consumer reporting agency at the same time the report is provided to Kelly.

4 Applicants/employees in New York:

By checking this box, I acknowledge that I have received a copy of New York Article 23-A.

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