Disclosure and Authorization Section
The Agency and/or its agents may obtain information about you from a consumer reporting agency. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include, but is not limited to information about your character, general reputation, personal characteristics and/or mode of living, employment history, work experience, work performance, criminal history records, sexual offender’s lists, motor vehicle records, military records, educational verification, license verification, credit history, government exclusion lists, OIG, GSA, FBI finger printing, and drug testing or other background checks. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. You also may request a written summary of Your Rights Under the Fair Credit Reporting Act. The scope of this notice and authorization is all-encompassing, however, allowing the Clinic to obtain from any individual or entity all manner of consumer reports and investigative consumer reports now and throughout the course of your relationship with the Clinic to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.
I hereby authorize and give my written instructions for the obtaining of “consumer reports” and/or “investigative consumer reports” by the Clinic at any time after receipt of this authorization and throughout my relationship with the Clinic. To this end, I hereby authorize, without reservation, any individual or entity to furnish any and all background information requested by American DataBank, 110 Sixteenth St., 8th Fl., Denver, CO 80202, 1-800-200-0853, or another outside organization acting on behalf of the Clinic. I also certify that all information I have provided to the Clinic is correct to the best of my knowledge. Any false statements provided will be considered just cause for denial of participation in the Clinic’s programs.
Upon request, American DataBank will supply a copy of my report and my rights under the Fair Credit Reporting Act. Requests may be directed to: American DataBank, 110 16th Street 8th Fl. Denver, CO 80202 or by contacting us at 1-800-200-0853.
Click here for a Summary of Rights Under the Fair Credit Reporting Act
California, Minnesota or Oklahoma Resident Only
By submitting, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO STATE LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under State law.
Have you or your spouse had any problems with the law in the past 10 years?
If yes, explain and list any arrests, convictions and sentences
Please list all states and counties that you have lived in in the past 10 years
What was your Maiden Name or other Married Name in each State & County