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P Human Resources Department * * P.O. Box 707 Concord, NC 28026 -0707 Phone: 704.920.2200 . Fax' 704.920.2250 • www.cabarruscounty.us iC.4 Disclosure & Authorization for Release of Personal Information (Personnel Records Are Maintained In Accordance With NCGS 153A -98) - Please Print Clearly" Return Completed Form to Human Resources Full Name (First, Middle, Last): _ List All Prior Names Used: Date of Birth (Month, Day, Year): Driver's License Number: Social Security Number: Street Address: City /State /Zip; Phone Number: { DISCLOSURE -- NOTICE REGARDING BACKGROUND INVESTIGATION Cabarrus County may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a "consumer report" and/or an "investigative consumer report" which may include information about your character, general reputation, personal characteristics, and/or mode of living and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. 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. Types of information that may be obtained include but are not limited to social security number verification, sex offender registry cheeks, criminal records checks, inmate records searches, motor vehicle retards, education, employment history, professional licenses, credit checks and court records checks. The information contained in these consumer reports may be obtained by an outside organization from public record sources and will not be used to discriminate against you in violation of any law. The scope of this Disclosure and Authorization is all- encompassing, allowing Cabarrus County to obtain from any outside organization all manner of consumer reports and Investigative consumer reports now and, if you are hired, throughout the course of your employment to the extent permitted by law. AUTHORIZATION AND ACKNOWLEDGMENT I acknowledge receipt of the DISCLOSURE - NOTICE REGARDING BACKGROUND INVESTIGATION and "A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT" and certify that I have read and understand both of those documents.. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, military branch, institution, school or university (public or private), information service bureau, past or present employer or supervisor, private business, insurance company or personal reference, and/or other persons to furnish any and all background information requested by any third -parry organization acting on behalf of Cabarrus County, and /or Cabarrus County itself. I agree that a facsimile ("fax") or photographic copy of this Authorization shall be as valid as the original. 04/25/16 PDFConvert. 1073 1. 1. Section 1- Driver Employee_ Selection - Copy State: DL Class (A, B. or C): Attachment Iumber 1 \n F -9 Page 190