Consumer Report Disclosure and Release

DISCLOSURE
In connection with your employment or application for employment, a “consumer report” and/or an “investigative consumer report”
may be requested from Beltrante & Associates, a consumer-reporting agency located at P.O. Box 7600, Alexandria, VA 22307,
1-800-423-0202. These reports may include information about your character, general reputation, personal characteristics, mode of
living and credit related matters. The scope of the investigation may include, but will not be limited to the following: Civil and
Criminal Records, Driving Record, Current and Past Residence Verifications, Education Verifications, Employment History, License
Verifications and Credit History. These consumer reports may be obtained at any time after receipt of your authorization and, if you
are hired, throughout your employment. You have the right to receive upon written request within a reasonable period of time, (not to
exceed 30 days) a complete and accurate disclosure of the nature and scope of the investigation requested. You have a right to make a
request to Beltrante & Associates, upon proper identification, to request the nature and substance of all information in its files on you
at the time of your request, including the sources of information. Attached to this disclosure is a written summary of your rights under
the Fair Credit Reporting Act (FCRA) as prepared by the Federal Trade Commission.

Minnesota Applicants or employees only: You may obtain a copy of your credit report if the Company obtains one by checking the “yes” box.  Yes
 No
Oklahoma Applicants or employees only: You may obtain a copy of your consumer report if the Company obtains one by checking the “yes” box.
 Yes  No

California applicants or employees only: By signing below, you also acknowledge receipt of the notice regarding Disclosure Concerning
Consumer Reports – California. Please check the box below if you would like a copy of your investigative consumer report or consumer
credit report if one is obtained by the Company at no charge whenever you have a right to receive such a copy under California law. 

AUTHORIZATION AND RELEASE

By signing below, I certify that I have read and fully understand this release, and that I executed this release voluntarily with the
knowledge that falsification or omission of information may result in immediate dismissal or retraction of any offer of employment, or
my eligibility for promotion.

I understand that I have specific prescribed rights as a consumer under the Federal Fair Credit Reporting Act (FCRA), and may have
additional rights under relevant state law. I hereby certify that I have been presented with a summary of my rights as a
consumer under the Fair Credit Reporting Act.

I hereby authorize ___________________________ (Company) and its designated agents and representatives, Beltrante &
Associates, a consumer-reporting agency bearing this release or copy thereof, to conduct an “Investigative Consumer Report,” a
“Consumer Report” or both for employment purposes. I further authorize, without reservation, any business, individual, school
or public agency that may have information relevant to this search to disclose such information to Beltrante & Associates or
its authorized agents pertaining to me. I hereby release Beltrante & Associates, its authorized agents, and all persons and
organizations providing information, from all claims and liabilities of any nature in connection with this research. I agree that a
facsimile (fax) or photocopy of this authorization shall be valid as the original for this and any future background investigation that be
deemed necessary.

For purposes of gathering this information, I agree to supply the identifying information listed below, which may be required by law enforcement
agencies and other entities for positive identification purposes when checking records. It is confidential and will not be used for any other purpose.

Today’s Date: _______________________Signature ___________________________________________________

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 IDENTIFYING INFORMATION FOR CONSUMER REPORTING AGENCY

APPLICANT OR CURRENT EMPLOYEE – PLEASE COMPLETE THIS SECTION

Print your full name:

(please include middle name)
(First) (Middle) (Last)
Print other names you have
used:
(Maiden names, Alias, other) (First) (Middle) (Last)

Current Address: House # Street: Apt #:

City: State: Zip:

List States and Counties of Residence for the past 7 years - Attach a separate sheet if more space is needed.

State: City/County/Zip: From: To:

State: City/County/Zip: From: To:

State: City/County/Zip: From: To:

State: City/County/Zip: From: To:

Social Security No.: Date of Birth: (mm/dd/yy)

Driver’s License No.: State of Issue:

Please use this space for any additional names, addresses or comments.

The information above is requested solely to compare with any data uncovered during this background
check/pre-employment screening investigation for employment purposes.

Page 2 of 2
Para informacion en espanol, visite www.ftc.gov/credit o escribe a la FTC Consumer Response Center, Room 130 -A 600 Pennsylvania
Ave. N.W., Washington, D. C. 20580.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies.
There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about
check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information,
including information about additional rights, go to www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade
Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.

• You must be told if information in your file has been used information about you to your employer, or a potential employer,
against you. Anyone who uses a credit report or another type of without your written consent given to the employer. Written consent
consumer report to deny your application for credit, insurance, or generally is not required in the trucking industry. For more
employment – or to take another adverse action against you – must information, go to www.ftc.gov/credit
tell you, and must give you the name, address, and phone number • You may limit “prescreened” offers of credit and insurance you
of the agency that provided the information. get based on information in your credit report. Unsolicited
• You have the right to know what is in your file. You may request “prescreened” offers for credit and insurance must include a toll-free
and obtain all the information about you in the files of a consumer phone number you can call if you choose to remove your name and
reporting agency (your “file disclosure”). You will be required to address from the lists these offers are based on. You may opt-out
provide proper identification, which may include your Social Security with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-
number. In many cases, the disclosure will be free. You are entitled 8688).
to a free file disclosure if: • You may seek damages from violators. If a consumer reporting
• a person has taken adverse action against you because of agency, or, in some cases, a user of consumer reports or a furnisher
information in your credit report; of information to a consumer reporting agency violates the FCRA,
• you are the victim of identify theft and place a fraud alert in your you may be able to sue in state or federal court.
file; • Identity theft victims and active duty military personnel have
• your file contains inaccurate information as a result of fraud; additional rights. For more information, visit www.ftc.gov/credit
• you are on public assistance; States may enforce the FCRA, and many states have their own
• you are unemployed but expect to apply for employment within consumer reporting laws. In some cases, you may have more rights
60 days. under state law. For more information, contact your state or local
In addition, by September 2005 all consumers will be entitled to consumer protection agency or your state Attorney General.
one free disclosure every 12 months upon request from each Federal enforcers are:
nationwide credit bureau and from nationwide specialty
consumer reporting agencies. See www.ftc.gov/credit for TYPE OF BUSINESS: CONTACT:
additional information. Consumer reporting agencies, creditors and Federal Trade Commission:
• You have the right to ask for a credit score. Credit scores are others not listed below Consumer Response Center - FCRA
numerical summaries of your credit-worthiness based on Washington, DC 20580 (877-382-4357)
information from credit bureaus. You may request a credit score National banks, federal branches/agencies of Office of the Comptroller of the Currency
from consumer reporting agencies that create scores or distribute foreign banks (word "National" or initials "N.A." Compliance Management, Mail Stop 6-6
scores used in residential real property loans, but you will have to appear in or after bank's name) Washington, DC 20219 (800-613-6743)
pay for it. In some mortgage transactions, you will receive credit Federal Reserve System member banks Federal Reserve Board
score information for free from the mortgage lender. (except national banks, and federal Division of Consumer & Community
• You have the right to dispute incomplete or inaccurate branches/agencies of foreign banks) Affairs
information. If you identify information in your file that is incomplete Washington, DC 20551 (202-452-3693)
or inaccurate, and report it to the consumer reporting agency, the Savings associations and federally chartered Office of Thrift Supervision
agency must investigate unless your dispute is frivolous. See savings banks (word "Federal" or initials Consumer Complaints
www.ftc.gov/credit for an explanation of dispute procedures. "F.S.B." appear in federal institution's name) Washington, DC 20552 (800-842-6929)
• Consumer reporting agencies must correct or delete Federal credit unions (words "Federal Credit National Credit Union Administration
inaccurate, incomplete, or unverifiable information. Inaccurate, Union" appear in institution's name) 1775 Duke Street
incomplete or unverifiable information must be removed or Alexandria, VA 22314 (703-519-4600)
corrected, usually within 30 days. However, a consumer reporting State-chartered banks that are not members Federal Deposit Insurance Corporation
agency may continue to report information it has verified as of the Federal Reserve System Consumer Response Center,
accurate. 2345 Grand Avenue, Suite 100
• Consumer reporting agencies may not report outdated Kansas City, Missouri 64108-2638
(877-275-3342)
negative information. In most cases, a consumer reporting agency
may not report negative information that is more than seven years Air, surface, or rail common carriers regulated Department of Transportation , Office of
by former Civil Aeronautics Board or Interstate Financial Management
old, or bankruptcies that are more than 10 years old.
Commerce Commission Washington, DC 20590 (202-366-1306)
• Access to your file is limited. A consumer reporting agency may
provide information about you only to people with a valid need -- Activities subject to the Packers and Department of Agriculture
Stockyards Act, 1921 Office of Deputy Administrator - GIPSA
usually to consider an application with a creditor, insurer, employer,
Washington, DC 20250 (202-720-7051)
landlord, or other business. The FCRA specifies those with a valid
need for access.
• You must give your consent for reports to be provided to
employers. A consumer reporting agency may not give out