Sapphire Check – Disclosure and Authorization Form


DISCLOSURE REGARDING
BACKGROUND INVESTIGATION ON YOU

(“the Company”) may obtain “consumer reports” about you
from a consumer reporting agency for employment purposes. A “consumer report”
is a background screening report that may contain information regarding your
criminal history, sex offender registry status, credit history, employment history,
education history, driving history, professional licenses, and other information
about you. It may bear upon your character, general reputation, personal
characteristics, and/or mode of living.


ADDITIONAL NOTICE REGARDING
INVESTIGATIVE CONSUMER REPORTS ON YOU

(“the Company”) may also request an “investigative
consumer report” on you from a consumer reporting agency.
An “investigative consumer report” is a background screening report generated
through personal interviews with sources such as your neighbors, friends, or
associates.
The consumer reporting agency that may prepare an “investigative consumer
report” on you for the Company is Sapphire Check LLC, 117 Ditmas Avenue,
Brooklyn, NY 11218, 888-993-4473. The information contained in an
“investigative consumer report” may bear upon your character, general reputation,
personal characteristics, and/or mode of living.
Please be advised that the nature and scope of the most common form of
“investigative consumer report” that may be ordered by the Company is an
investigation into your employment history. During such an investigation, Sapphire
Check may ask questions about your employment history to certain knowledgeable
individuals and provide response information to the Company.
Note: You have the right to request additional information regarding the
nature and scope of any “investigative consumer report” ordered by the
Company on you. You may do so by contacting the Company.

[END OF DOCUMENT]

ADDITIONAL STATE LAW NOTICES

If you live in, work in, or are seeking work for (“the Company”) in Washington
State, Massachusetts, New Jersey, New York, Minnesota, Oklahoma, or California, please note the
following information which we are required by state law to provide to you:

State of Washington applicants/employees only: If the Company requests an investigative
consumer report (as defined by state law) from a consumer reporting agency, you have the right
to receive a complete and accurate disclosure of the nature and scope of the investigation
requested by the Company. You also have the right to request a written summary of your rights
and remedies under the Washington Fair Credit Reporting Act.
Massachusetts applicants/employees only: If the Company requests an investigative consumer
report (as defined by state law) from a consumer reporting agency, you have the right to have a
copy of the report upon request.
New Jersey applicants/employees only: If the Company requests an investigative consumer
report (as defined by state law) from a consumer reporting agency, you have the right to have a
copy of the report upon request.
New York applicants/employees only: You have the right, upon written request, to be informed
of whether or not an investigative consumer report (as defined by state law) was requested from
a consumer reporting agency. If a report was requested, you will be provided with the name and
address of the consumer reporting agency to whom the request was made. You may also inspect
and receive a copy of the report by contacting Sapphire Check LLC, 117 Ditmas Avenue,
Brooklyn, NY 11218, 888-993-4473. You are also now receiving a copy of Article 23-A of the
NY Correction Law.
Minnesota applicants/employees only: You have the right, upon written request, to receive a
complete and accurate disclosure of the nature and scope of the consumer report. A consumer
reporting agency must make this disclosure within five (5) days of receipt of your request or of
the Company’s request for the report, whichever is later. Please check this box if you would
like to receive a copy of a consumer report if one is obtained by the Company. 
Oklahoma applicants/employees only: Please check this box if you would like to receive a copy
of a consumer report if one is obtained by the Company. 
California applicants/employees only: You are separately receiving a copy of the Notice
Regarding Background Investigation Pursuant To California Law.
[END OF DOCUMENT]

NOTICE REGARDING BACKGROUND INVESTIGATION

PURSUANT TO CALIFORNIA LAW
(For California Applicants and Employees Only)

(“the Company”) intends to obtain information about you from an investigative
consumer reporting agency for employment purposes. Thus, you can expect to be the subject of
“investigative consumer reports” obtained for employment purposes. Such reports may include
information about your character, general reputation, personal characteristics, and mode of living. With
respect to any investigative consumer report from an investigative consumer reporting agency (“ICRA”),
the Company may investigate the information contained in your employment application and other
background information about you, including but not limited to: your criminal history, sex offender
registry status, driving history, education history, employment history, credit information, and
professional licenses. The Company may also obtain comments from individuals who are knowledgeable
about you. These reports may be used as a factor in making employment decisions. The source of any
investigative consumer report (as that term is defined under California law) will be Sapphire Check LLC,
117 Ditmas Avenue, Brooklyn, NY 11218, 888-993-4473. Information regarding Sapphire Check’s
privacy practices (including information about whether any consumer personal information will be sent
outside the U.S. or its territories) may be found at https://www.sapphirecheck.com/.
Under California Civil Code section 1786.22, you are entitled to find out from an ICRA what is in the
ICRA’s file on you with proper identification, as follows:
 In person, by visual inspection of your file during normal business hours and upon reasonable notice.
You also may request a copy of the information in person. The ICRA may not charge you more than
the actual copying costs for providing you with a copy of your file.
 By requesting a copy be sent to a specified addressee by certified mail. ICRAs complying with
requests for certified mailings shall not be liable for disclosures to third parties caused by
mishandling of mail after such mailings leave the ICRAs.
 A summary of all information contained in the ICRA’s file on you (which is required to be provided
by the California Civil Code) will be provided to you via telephone, if you have made a written
request for telephone disclosure and the toll charge, if any, for the telephone call is prepaid by or
charged directly to you.
“Proper Identification” includes documents such as a valid driver’s license, social security account
number, military identification card, and credit cards. Only if you cannot identify yourself with such
information may the ICRA require additional information concerning your employment and personal or
family history in order to verify your identity.
The ICRA will provide trained personnel to explain any information furnished to you and will provide a
written explanation of any coded information contained in files maintained on you. This written
explanation will be provided whenever a file is provided to you for visual inspection.
You may be accompanied by one other person of your choosing, who must furnish reasonable
identification. An ICRA may require you to furnish a written statement granting permission to the ICRA
to discuss your file in such person’s presence.
Please check this box if you would like to receive a copy of an investigative
consumer report (as defined by relevant state law) at no charge if one is obtained by
the Company. 

AUTHORIZATION REGARDING BACKGROUND INVESTIGATION
By signing below, I acknowledge receipt of the following separate documents (and certify that I
have read and understood them):
. DISCLOSURE REGARDING BACKGROUND INVESTIGATION ON YOU;
. A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT;
.ADDITIONAL NOTICE REGARDING INVESTIGATIVE CONSUMER REPORTS ON
YOU;
 ADDITIONAL STATE LAW NOTICES.
By signing below, I also authorize to obtain “consumer reports” and
“investigative consumer reports” about me for employment purposes at any time during the
hiring process and throughout my employment, if applicable.

Signature Date

Printed

PERSONAL INFORMATION NEEDED FOR BACKGROUND CHECK Please supply the following information to facilitate a background check on you. Full Name (First, middle, last):

Social Security Number:

Date of Birth:

Driver License No.:

State Issued:



Full Current Address

Additional Previous Address Within the Last 7 Years Additional Previous Address Within the Last 7 Years

Leave this empty:

Signature arrow
Sapphire Background Check https://www.sapphirecheck.com
Signature Certificate
Document name: Sapphire Check – Disclosure and Authorization Form
lock iconUnique Document ID: 0410530acc1a505084c23a2035db2f29f7aea01b
Timestamp Audit
September 12, 2020 6:59 am ESTSapphire Check – Disclosure and Authorization Form Uploaded by Sapphire check - support@sapphirecheck.com IP 125.62.98.8