Background Check Form Consumer Rights Summary (PDF) PLEASE FILL OUT THE ENTIRE FORM.Applicant/Employee InformationFirst NameMiddleLastAlias/Maiden Name:(s)PhoneEmail AddressDriver's License Number:State of IssuanceSocial Security NumberDate of BirthLIST ALL ADDRESSES DURING THE PAST 7 YEARSDatesCurrent AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeDatesPrevious AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeDatesPrevious AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeDatesPrevious AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeDatesPrevious AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeDatesPrevious AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeSIGNATUREConsent *AUTHORIZATION FOR CONSUMER REPORTS I hereby authorize the procurement of consumer report(s) and investigative consumer report(s) by Thermal Service Solutions, LLC. If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for Thermal Service Solutions, LLC to procure such reports at any time during my employment, contract, or volunteer period. I authorize without reservation, any person, business or agency contacted by the consumer reporting agency to furnish the above-mentioned information. This authorization is conditioned upon the following representations of my rights: I understand that I have the right to make a request to the consumer reporting agency: Datasource, Inc (“Agency”), 1200 South Outer Road, Blue Springs, MO 64015, telephone number (877) 577-3832, upon proper identification, to obtain copies of any reports furnished to Thermal Service Solutions LLC by the Agency and to request the nature and substance of all information in its files on me at the time of my request, including the sources of information, and the Agency, on Thermal Service Solutions, LLC’s behalf, will provide a complete and accurate disclosure of the nature and scope of the investigation covered by any investigative consumer report(s). The Agency will also disclose the recipients of any such reports on me which the Agency has previously furnished within the two year period for employment requests, and one year for other purposes preceding my request (California three years). I hereby consent to Thermal Service Solutions, LLC obtaining the above information from the Agency. I understand that I can dispute, at any time, any information that is inaccurate in any type of report with the Agency. I may view the Agency’s privacy policy at their website: www.datasourcecorp.com. I understand that I have rights under the Fair Credit Reporting Act, and I acknowledge receipt of the Summary of Rights. Consent *DISCLOSURE FOR CONSUMER REPORTS In connection with my application for employment (including contract or volunteer services), or application to rent a dwelling, I understand consumer reports will be requested by you (“Thermal Service Solutions, LLC”). These reports may include, as allowed by law, the following types of information, as applicable: names and dates of previous employers, reason for termination of employment, work experience, reasons for termination of tenancy, former landlords, education, accidents, licensure, credit, etc. I further understand that such reports may contain public record information such as, but not limited to: my driving record, workers’ compensation claims, judgments, bankruptcy proceedings, evictions, criminal records, etc., from federal, state, and other agencies that maintain such records. In addition, investigative consumer reports (gathered from personal interviews, as applicable, with former employers or landlords, past or current neighbors and associates of mine, etc.) to gather information regarding my work or tenant performance, character, general reputation and personal characteristics, and mode of living (lifestyle) may be obtained. If I am hired, I understand that my employer can use this disclosure and authorization to continue to obtain such consumer reports throughout my employment, contract period or volunteer service.PRINT NAME FOR ELECTRONIC SIGNATURE *Date *SubmitPlease do not fill in this field.