DE LA SALLE NORTH CATHOLIC HIGH SCHOOL BACKGROUND AUTHORIZATION FORM

Date of Request:______

This section to be completed by the applicant/volunteer. Please print legibly and in black ink.

Position applied for: ______Employee or Volunteer/3rd party:______

Gender:: ____ Female ____ Male

Applicant Name: ______First Middle Last

Applicant Address: ______

______City State Zip

Other names used and dates of name changes (include maiden name):

______

Email address: ______Phone #: ______

Social Security #: _____/_____/_____ Driver’s License: ______

Birth Date: ______/_____/_____ State License Issued: ______

If you have lived in a state other than Oregon in the past 10 years, please list the following information, including the years in which you lived there. Please continue on the reverse side of this form if more room is needed.

State ______City ______Years: ______to ______

Have you ever been convicted of a crime (excluding minor traffic violations? ____Yes ___ No If yes, please state offense, place and date of conviction: ______

Have you ever been charged with a criminal offense involving children? Yes ___ No ___ If yes, give details: ______

All employment offers are contingent on the satisfactory result of the applicant’s background investigation. Page 1 of 2 Revised 6/4/2018 Please attach a copy of your driver’s license or other photo ID. Please read and sign the authorization on the other side of this form.

DISCLOSURE AND AUTHORIZATION REGARDING PROCUREMENT OF BACKGROUND REPORTS

To assist us in making quality employment-related decisions and in order to comply with federal and state statutes and regulations, De La Salle North Catholic High School (“DLSNC”) may obtain from a credit reporting agency a consumer report or investigative consumer report containing financial and other information about you during the pre-employment screening process. If DLSNC employs you, we may also obtain and use consumer reports to make appropriate inquiries to evaluate you for promotion, reassignment or retention as an employee.

DLSNC complies with the Fair Credit Reporting Act (“FCRA”) and applicable state statutes and regulations, which provide applicants and employees with rights regarding consumer reports and investigative consumer reports and places specific obligations on employers using credit. DLSNC does not request, and will not consider, information pertaining to your credit history unless that information is substantially related to the position for which your application is being considered. If applicable, you will be specifically informed of the DLSNC’s intent to obtain and consider that information. Although this disclosure and authorization encompasses criminal history reports, such reports will be requested only after a conditional offer of employment is extended to you. No criminal history inquiries will be made nor will any criminal history considered prior to the Company making a conditional offer of employment to you.

If DLSNC obtains a “consumer report” about you and considers any information in the “consumer report” when making an employment-related decision that directly and adversely affects you, you will be provided with a copy of the “consumer report” before the decision is finalized. You also may contact the Consumer Financial Protection Bureau about your rights under FCRA as a “consumer” with regard to “consumer reports” and “consumer reporting agencies.” Please also see “A Summary of Your Rights Under the Fair Credit Reporting Act,” which is enclosed.

AUTHORIZATION

I understand that consumer reports and/or investigative consumer reports may be made on me which may include information regarding my background, character, general reputation, personal characteristics, trustworthiness, employment history and work performance, security clearance, credit standing and credit capacity as a condition of my employment with DLSNC. I understand that criminal history inquiries will not be made if DLSNC does not extend a conditional offer of employment to me, that criminal history inquiries may be made upon DLSNC extending a conditional offer of employment to me, and that a conditional offer of employment may be conditioned on successfully passing a criminal history inquiry. If I include a current employer for verification, I understand that the current employer may be contacted or learn of my application for employment, which may jeopardize my position within that company.

I authorize and consent without reservation to DLSNC’s procurement of any consumer reports or investigative consumer reports from PRAESIDIUM, whether or not such reports are subject to the FCRA. I authorize, without reservation, any person or entity contacted by DLSNC or its agents and representatives to furnish information regarding my background, character, general reputation, personal characteristics, trustworthiness, employment history and work performance, security clearance, credit standing and credit capacity. I further specifically authorize, without reservation, any person or entity contacted by DLSNC or its agents and representatives to furnish information regarding my criminal history, if any, after the extension of a conditional offer of employment to me. I hereby release any person or entity from any liability for furnishing such information, and I also release DLSNC from any and all liability for conducting such an investigation. This authorization and consent shall be valid in original, fax, electronic or copy form. I further authorize ongoing procurement of the above mentioned reports at any time during my employment (or contract).

By signing this document, I agree I have read and understand all of the above and have been extended a conditional offer of employment by DLSNC.

Signature______Date______

Page 2 of 2 Revised 6/4/2018