5390
Client ID: ___________
J.J. White, Inc.
Client Name: _______________________________
DISA Background Screening Consent Form
NABSC and Reciprocal Consortiums
DISA Contractors Consortium, 10900 Corporate Centre Drive Suite 250, Houston, TX 77041
NOTICE AND ACKNOWLEDGEMENT FOR BACKGROUND INVESTIGATION
IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING ACKNOWLEDGMENT
Your employer may obtain information about you from a consumer reporting agency for employment or other permissible 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. These reports may include employment history and reference checks, motor vehicle history (“driving records”), sex
offender status, Social Security Verification/Trace, national criminal database searches, and Terrorist Watch list information. These reports may be
obtained at any time after receipt of your authorization and, if you are hired, throughout your employment.
These reports will be reported to the employer of record. Information in these reports may result in restricting your access to some Owner's facilities who
are participating in the North American Background Screening Consortium (NABSC) or the DISA Contractor Consortium. For more information on the
NABSC Program, refer to the NABSC program description.
The information in the consumer report will be used to generate a background screen grade. Each Owner participating will provide the maximum
background screen grade that will be allowed for Contractor Employees to be eligible for access to that Owner's site. DISA Global Solutions, Inc or the
NABSC Program Lookup Application will compare the Owner's requirements to the background screen grade provided by DISA Global Solutions, Inc,
Inc to classify you with either an Active or Inactive status for that Owner's site.
• If you do not meet a particular Owner's background screen security requirements, you will be classified as Inactive for that Owner's site.
• If you meet a particular Owner's background screen security requirements, you will be classified as Active for that Owner's site.
If you have an Active status for an Owner's site, you will be eligible for access to that Owner's property. However, any Owner reserves the right to allow
or deny access without regard to background screening eligibility.
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. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with
regard to applicants or employees is an investigation into your employment history conducted by DISA Global Solution, Inc (10900 Corporate Centre
Drive, Suite 250, Houston, TX, 77041 (800)752-6432) or another outside organization. The scope of this notice and authorization is all-encompassing,
however, allowing the employer to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and
throughout the course of your employment with the employer to the extent is 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. Owners, Contractor Employers and reciprocal
Safety Councils participating in the NABSC Program and DCC will have access to verify your background screen security status (Active or Inactive)
for a particular Owner site.
Participating Owners and reciprocal Safety Councils will not have access to the details of the background report without additional
authorization by you.
ACKNOWLEDGMENT AND AUTHORIZATION
I acknowledge receipt of the 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 for a period of two years from the completion of the background screen. I further authorize and direct DISA to make available my
subsequent background screen grade to the NABSC Program Lookup Application or any other Owner participating in a DISA Background Screening
Consortium for the purpose of determining my eligibility for access to Owner's facilities. To these ends, I hereby authorize, without reservation, any law
enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer,
insurance company, or any other source to furnish any and all background information requested by DISA, another outside organization acting on behalf of
DISA, the NABSC Program Custodian, and/or the employer itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization
shall be as valid as the original.
Please Note: This form does not place a background order.
Applicant Name: Applicant SSN:
Witness: Location:
Signature: Date:
Witness: Date:
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