BACKGROUND SCREENING RELEASE and AUTHORIZATION FORM
In connection with my application for employment (including contract for services or volunteer services) or tenancy
with Crabtree Amusements (Company Name), consumer reports will be requested. These consumer reports
(investigative consumer reports in California) may include, as applicable, the following types of information: names
and dates of previous employers/landlords, salary, work/tenant experience, education, accidents, licensure, credit
(except California), etc. I further understand that such reports may contain public record information such as, but not
limited to: my driving record, workers’ compensation claims, judgments, evictions, bankruptcy proceedings, criminal
records, etc., from federal, state and other agencies which maintain such records.
In addition, investigative consumer reports as defined by the federal Fair Credit Reporting Act, gathered from
personal interviews with former employers/landlords and other past or current associates of mine to gather
information regarding my work/tenant performance, character, general reputation, personal characteristics and
lifestyle may be obtained.
I have the right to make a request to the consumer reporting agency: MedReview, LLC 200 Morris Drive Harrisburg
NC 28075 (704) 455-7000 (“Agency”), upon proper identification, to request the nature and substance of all
information in its files on me at the time of my request, including the sources of information and the agency, on our
behalf, will provide a complete and accurate disclosure of the nature and scope of the investigation covered by any
consumer report(s); and the recipients of any reports on me which the agency has previously furnished within the
two year period for employment requests, and one year for other purposes preceding my request (California three
I hereby authorize procurement of consumer report(s) and investigative consumer report(s), including the release
of all criminal records. If hired (or contracted), this authorization shall remain on file and shall serve as ongoing
authorization for you to procure consumer reports at any time during my employment (or contract) period.
California, Minnesota and Oklahoma Applicants only: Check box if you request a copy of any consumer report
ordered on you.
Notice to California Applicants:
You have the right under Section 1786.22 of the California Civil Code to contact the Agency during reasonable hours
(9:00 a.m. to 5:00 p.m. (EST) Monday through Friday) to obtain all information in your file for your review. You may
obtain such information as follows:
1) In person at the Agency’s offices, which address is listed above. You can have someone accompany you to the
Agency’s offices. Agency may require this third party to present reasonable identification. You may be required at the
time of such visit to sign an authorization for Agency to disclose to or discuss your information with this third party;
2) By certified mail, if you have previously provided identification in a written request that your file be sent to you or
to a third party identified by you;
3) By telephone, if you have previously provided proper identification in writing to Agency; and
4) Agency has trained personnel to explain any information in your file to you and if the file contains any information
that is coded, such will be explained to you.
Notice to New York Applicants:
For consumers applying for work in New York: I acknowledge receiving a copy of Article 23-A of the New York
Para información en español, visite www.consumerfinance.gov/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 www.consumerfinance.gov/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 identify 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 www.consumerfinance.gov/
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 www.consumerfinance.gov/learnmore for an explanation of dispute procedures.
• 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 www.
consumerfinance.gov/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 1-888-567-8688.
• 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
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:
1.a. Banks, savings associations, and credit unions with total assets
of over $10 billion and their affiliates:
b. Such affiliates that are not banks, savings associations, or credit
unions also should list, in addition to the CFPB:
a. Consumer Financial Protection Bureau
1700 G Street NW
Washington, DC 20552
b. Federal Trade Commission: Consumer Response Center – FCRA
Washington, DC 20580
2. To the extent not included in item 1 above:
a. National banks, federal savings associations, and federal
branches and federal agencies of foreign banks
b. State member banks, branches and agencies of foreign banks
(other than federal branches, federal agencies, and Insured State
Branches of Foreign Banks), commercial lending 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 Branches of Foreign
Banks, and insured state savings associations
d. Federal Credit Unions
a. Office of the Comptroller of the Currency
Customer Assistance Group
1301 McKinney Street, Suite 3450
Houston, TX 77010-9050
b. Federal Reserve Consumer Help Center
P.O. Box 1200
Minneapolis, MN 55480
c. FDIC Consumer Response Center
1100 Walnut Street, Box #11
Kansas City, MO 64106
d. National Credit Union Administration
Office of Consumer Protection (OCP)
Division of Consumer Compliance and Outreach (DCCO)
1775 Duke Street
TYPE OF BUSINESS: CONTACT:
3. Air carriers Asst. General Counsel for Aviation Enforcement &
Aviation Consumer Protection Division
Department of Transportation
1200 New Jersey Avenue, SE
Washington, DC 20590
4. Creditors Subject to Surface Transportation Board Office of
Surface Transportation Board Department of Transportation
395 E Street S.W.
Washington, DC 20423
5. Creditors Subject to Packers and Stockyards Act, 1921
Nearest Packers and Stockyards Administration area supervisor
6. Small Business Investment Companies Associate Deputy
Administrator for Capital Access:
United States Small Business Administration
409 Third Street, SW, 8th Floor
Washington, DC 20416
7. Brokers and Dealers Securities and Exchange Commission
100 F St NE
Washington, DC 20549
8. Federal Land Banks, Federal Land Bank Associations, Federal
Intermediate Credit Banks, and Production Credit Associations
9. Retailers, Finance Companies, and All Other Creditors Not
Farm Credit Administration
1501 Farm Credit Drive
McLean, VA 22102-5090
FTC Regional Office for region in which the creditor operates or
Federal Trade Commission: Consumer Response Center – FCRA
Washington, DC 20580(877) 382-4357