How to submit your background check request

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1 Background Request Form How to submit your background check request 1. If you have not yet created a Banner Learning Center (BLC) account, STOP! You must create this account prior to sending in your background consent forms. See Attachment A, see pages Please complete ALL fields on pages 2, 3, 4 and 5. If the information requested does not apply, please indicate by marking N/A in the space provided. Any blank spaces may cause delays in processing the background check. 3. If you are a CURRENT resident of the state of New York, complete page If you have a CURRENT motor vehicle license in the state of Alaska, complete page If you have a CURRENT motor vehicle license in the state of Washington, complete page Fax ONLY pages 2, 3, 4 and 5. (Include pages 12, 16, or 17 if applicable). 7. A summary of your rights is provided for you in both English and Spanish, see pages You will receive an affirming Secure Hire s receipt of your application by 6:00PM daily. 1

2 B A C K G R O U N D C H E C K C O V E R S H E E T COMPLETE ALL DOCUMENTS AND SUBMIT VIA SECURE FAX TO: LOCAL FAX: OR * TOLL FREE FAX: NOTICE: TO AVOID DELAYS PLEASE COMPLETE ALL FIELDS EMPLOYEE/STUDENT STATUS Is applicant a Banner Employee? Is applicant participating in the Online Clinical Orientation System (OCOS)? YES NO YES NO If YES, please indicate Lawson ID number If YES, please indicate user name: If NO, please indicate Banner Learning Center (BLC) user name: This section MUST be completed or the application will be rejected. EMPLOYEE/STUDENT DEMOGRAPHIC INFORMATION APPLICANT NAME (Last, First Middle Initial-please print) SCHOOL NAME (College, University, Institution, etc.) PLEASE IDENTIFY TYPE OF APPLICANT STUDENT FACULTY OTHER, If other, please identify: APPLICANT ADDRESS APPLICANT PHONE NUMBER ( ) - PROGRAM TYPE (Nursing, Pharmacy, etc) FACULTY/ REP CONTACT NAME FACULTY/REP PHONE NUMBER ( ) - BANNER FACILITY (e.g. Thunderbird, Northern Colorado, etc.) NOTES/COMMENTS: DATE SUBMITTED / / (MM/DD/YYYY) B A N N E R H E A L T H S E C U R E H I R E W B R O W N R D S U I T E M E S A A Z

3 Facility Position Start Date Estimate / / DISCLOSURE AND AUTHORIZATION TO OBTAIN INVESTIGATIVE CONSUMER REPORT FOR PERSONS SEEKING EDUCTIONAL AFFILIATION As part of my application for educational placement with Banner Health, I understand that Banner Health may obtain an Investigative Consumer Report ("Report"), which may include information as it pertains to my character, general reputation, personal characteristics, mode of living and work habits. Such a Report may be requested by Banner Health and/or its designated agents on behalf of Banner Health. These Reports may include information relating to my past job performance and experience, including reasons for termination, professional license and education verification, criminal and civil litigation history, driving records and/or other reports. Further, I understand that information will be requested from various federal, state, county or other agencies that maintain records. The scope of any subsequent consumer report will contain the same elements identified in the pre-employment background check. The purpose of the investigation will be to determine my continued suitability for patient contact or whether I possess the minimum qualifications necessary for promotion, or transfer to another position. If I apply to become or become a Banner Health employee the Report will also be used to evaluate me for employment, promotion, reassignment or retention as an employee. The nature, scope and purpose of any subsequent report will be the same as the nature, scope and purpose of a pre-employment report. I understand that I will receive a copy of the A Summary of Your Rights provided by the federal Fair Credit Reporting Act (FCRA). To obtain more information about my Report, I may contact or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C THIS REPORT IS BEING OBTAINED BY: BANNER HEALTH SECURE HIRE 525 W Brown Rd, Suite 3318 Mesa, AZ Toll Free *****NOTICE TO CALIFORNIA, OKLAHOMA, MINNESOTA, AND NEW YORK APPLICANTS***** You have the right to obtain a copy of any Investigative Consumer Report obtained by Banner Health by checking the box provided below. The Report will be provided to you within three (3) business days after the Report is provided to Banner Health. Although the State Laws of CA, OK, MN, and NY require this statement; any resident of any state may obtain a free copy of this Report by marking the box below: I request to receive a free copy of this Report by checking this box. Initial / / Date Consent Page 1 of 2 3

4 California Residents, please note that under section of the California Civil Code, you may view the file maintained on you during normal business hours. You may also obtain a copy of the file upon submitting proper identification and paying the costs of duplication services, if applicable, you may also receive by mail or a summary of the file by telephone. Banner Health Secure Hire will have personnel available to explain to you any coded information appearing in your file. If you appear in person, a person of your choice may accompany you, provided that this person furnishes proper identification. New York Residents have the right to request the nature and substance of all information obtained on your behalf by Banner Health Secure Hire, including the sources of information, as well as the recipients of Background Reports within the two (2) year period preceding the request. New York Residents are entitled to receive a copy of the New York Correction Law also known as Article 23-A (attached) which pertains to the Licensure and Employment of Persons Previously Convicted of One or More Criminal Offenses. To initiate such request, contact Henrietta Williams, Director of Banner Health Secure Hire, at 525 W. Brown Road, Suite 3318, Mesa, AZ 85201, via at or via toll free phone at I acknowledge that Banner Health Secure Hire will request, and I must supply, proper identification should such request be made. This Disclosure and Authorization to Obtain Investigative Consumer Report, in original, faxed, photocopied or electronic form will be valid for any Reports that may be requested by Banner Health. I authorize Banner Health, Banner Health Secure Hire and/or its designated agents, without reservation, permission to release all applicable records pertaining to the subject matter of this Disclosure and Authorization to Obtain Investigative Consumer Report. Print Name Social Security Number Date of Birth: (MM/DD/YYYY) Signature Signature Date: (MM/DD/YYYY) Consent Page 2 of 2 4

5 APPLICANT INFORMATION Full Name BACKGROUND CHECK INFORMATION SHEET Social Security Number - - Names Used Please list all other names including maiden, alias, etc. Driver s License No. (Please Include State of Issue) Address of Applicant (be sure to include street, city, state and zip code) Street: City: State: Zip Code: Contact Information Home Phone: ( ) - Other Phone: ( ) - CRIMINAL HISTORY (Disclosure of previous convictions will not automatically disqualify you from consideration) Have you ever been convicted of a crime? No Yes If yes, please explain and include date(s), location and nature of offense ADDRESS HISTORY (Please list all previous CITIES/STATES of residence, employment and education) Address (example: Dallas, Texas) Dates (example: from 01/01/2001 to 01/01/2011) I authorize Banner Health, Banner Health Secure Hire and/or its designated agents to verify the information set forth on this Background Check Information Sheet. I authorize the procurement of an investigative report and understand that it may contain information pertaining to my past job performance and experience, including reasons for termination, professional license and education verification, criminal and civil litigation history, driving records and/or other reports. I hereby certify this information to be true and correct to the best of my knowledge and belief. Printed Name: Signature: Date (MM/DD/YYYY) / / 5

6 Para informacion en espanol, visite o escribe a la FTC Consumer Response Center, Room 130-A 600 Pennsylvania Ave. N.W., Washington, D.C 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 or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment or to take another adverse action against you must tell you, and must give you the name, address, and phone number of the agency that provided the information. You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your file disclosure ). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if: a person has taken adverse action against you because of information in your credit report; you are the victim of identity theft and place a fraud alert in your file; your file contains inaccurate information as a result of fraud; you are on public assistance; you are unemployed but expect to apply for employment within 60 days. In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See for additional information. You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender. You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See for an explanation of dispute procedures. 6

7 Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate. Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old. Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, 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 information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to You may limit prescreened offers of credit and insurance you get based on information in your credit report. Unsolicited prescreened offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at OPTOUT ( ). You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court. Identity theft victims and active duty military personnel have additional rights. For more information, visit 7

8 States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. Federal enforcers are: Consumer Reporting Agencies, TYPE OF BUSINESS: creditors and others not listed below CONTACT: Federal Trade Commission: Consumer Response Center - FCRA Washington, DC National banks, federal branches/agencies of foreign banks (word "National" or initials "N.A." appear in or after bank's name) Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks) Federal Reserve Consumer Help (FRCH) P O Box 1200 Minneapolis, MN Telephone: Website Address: Address: Savings associations and federally chartered savings banks (word "Federal" or initials "F.S.B." appear in federal institution's name) Office of Thrift Supervision Consumer Complaints Washington, DC Federal credit unions (words "Federal Credit Union" appear in institution's name) National Credit Union Administration 1775 Duke Street Alexandria, VA State-chartered banks that are not members of the Federal Reserve System Federal Deposit Insurance Corporation Consumer Response Center, 2345 Grand Avenue, Suite 100 Kansas City, Missouri Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission Department of Transportation, Office of Financial Management Washington, DC Activities subject to the Packers and Stockyards Act, 1921 Department of Agriculture Office of Deputy Administrator - GIPSA Washington, DC

9 Un Resumen de Sus Derechos en Virtud de la Ley de Informe Justo de Crédito La Ley Federal de Informe Justo de Crédito (Fair Credit Reporting Act, FCRA) fomenta la exactitud, justicia y privacidad de la información en los expedientes de las agencias de informe del consumidor. Existen muchos tipos de agencias de informe del consumidor, incluyendo las agencias de crédito (credit bureaus) y las especializadas (como agencias que venden información sobre historial de firma de cheques, expedientes médicos e historial de alquiler). A continuación tiene un breve resumen de sus principales derechos en virtud de la FCRA. Para más información, incluyendo información sobre derechos adicionales, visite o escriba a: Consumer Response Center, Room 130- A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C Deben notificarle si la información en su expediente se ha utilizado en contra de usted. Todo aquel que utilice un informe de crédito u otro tipo de informe de consumidor para denegar su solicitud de crédito, seguro o empleo, o para emprender otra acción contra usted, debe informarle y debe darle el nombre, la dirección y el teléfono de la agencia que proporcionó esa información. Tiene derecho a saber lo que está en su expediente. Puede solicitar y obtener toda la información sobre usted en los archivos de una agencia de informe del consumidor. Deberá proporcionar identificación, que puede incluir su número de Seguro Social. En muchos casos, la divulgación de esta información será gratuita. Tiene derecho a una divulgación gratuita si: una persona ha emprendido una acción adversa contra usted debido a información en su informe de crédito; usted es víctima de un robo de identidad y se coloca una alerta de fraude en su expediente; su expediente contiene información no exacta como resultado de fraude; usted recibe asistencia pública; no está empleado pero anticipa solicitar empleo en 60 días. Asimismo, para septiembre de 2005, todos los consumidores tendrán derecho a una divulgación cada 12 meses si así lo solicitan a cada agencia de crédito nacional y de las agencias nacionales de informe del consumidor especializadas. Para información adicional, visite Tiene derecho a pedir su puntuación de crédito. Las puntuaciones de crédito son resúmenes numéricos de su valía de crédito basados en información de las agencias de crédito. Puede solicitar una puntuación de crédito de agencias de informe del consumidor que crean puntuaciones o distribuyen las puntuaciones utilizadas en préstamos de bienes raíces residenciales, pero tendrá que pagar para recibirla. En algunas transacciones hipotecarias, el prestamista le dará gratuitamente información sobre su puntuación de crédito. 9

10 Tiene derecho a confrontar información incompleta o no exacta. Si identifica información en su expediente que es incompleta o inexacta, y la reporta a la agencia de informe del consumidor, la agencia debe investigar a menos que su confrontación sea frívola. Visite para una explicación de los procedimientos de confrontación. Las agencias de informe del consumidor deben corregir o eliminar información inexacta, incompleta o no verificable. La información no exacta, incompleta o no verificable debe ser retirada o corregida, generalmente dentro de 30 días. No obstante, una agencia de informe del consumidor puede seguir reportando información si ha verificado su exactitud. Las agencias de informe del consumidor no pueden reportar información negativa atrasada. En la mayoría de los casos, una agencia de informe del consumidor puede no reportar información negativa ocurrida hace más de siete años, ni quiebras ocurridas hace más de 10 años. El acceso a su expediente es limitado. Una agencia de informe del consumidor puede proporcionar información sobre usted solamente a personas que realmente la necesiten generalmente para considerar una solicitud con un acreedor, asegurador, empleador, propietario de vivienda u otro negocio. La FCRA especifica quiénes son las personas que tienen una necesidad válida de acceso. Debe otorgar su consentimiento para que se envíen sus informes a empleadores. Una agencia de informe del consumidor no puede dar información sobre usted a su empleador, o a un posible empleador, sin su consentimiento escrito previo otorgado al empleador. El consentimiento escrito generalmente no es requerido en la industria de camiones. Para más información visite Puede limitar las ofertas preevaluadas de crédito y seguro que obtiene basadas en información en su informe de crédito. Las ofertas preevaluadas de crédito y seguro deben incluir un número de teléfono sin cargo al que puede llamar si desea eliminar su nombre y dirección de las listas en las que se basan estas ofertas. Puede optar por no figurar en las listas de las agencias de crédito llamando al OPTOUT ( ). Puede obtener compensación de los acreedores. Si una agencia de informe del consumidor, o en algunos casos, un usuario de informes de consumidor o proveedor de información a una agencia de informe del consumidor infringe la FCRA, usted puede presentar un pleito en un tribunal estatal o federal. Las víctimas de robo de identidad y el personal militar en activo tienen derechos adicionales. Para más información, visite 10

11 Los estados tienen autoridad para hacer cumplir la FCRA, y muchos estados tienen su propia legislación de informe del consumidor. En algunos casos, usted puede tener más derechos en virtud de la ley estatal. Comuníquese con su agencia de protección estatal o local del consumidor o su Fiscal general estatal. Las agencias a nivel federal son: TIPO DE NEGOCIO: Agencias de informe del consumidor, acreedores y otros no mencionados abajo CONTACTAR: Federal Trade Commission: Consumer Response Center - FCRA Washington, DC Bancos nacionales, sucursales/agencias federales de bancos extranjeros (con la palabra National o las iniciales N.A. en o después del nombre del banco) Bancos que pertenecen al Sistema de la Reserva Federal (salvo bancos nacionales, y sucursales/agencias federales de bancos extranjeros) Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC Federal Reserve Consumer Help (FRCH) P O Box 1200 Minneapolis, MN Telephone: Website Address: Address: Asociaciones de ahorros y cajas de ahorros con acreditación federal (con la palabra Federal o las iniciales F.S.B. en el nombre de la institución federal) Bancos de crédito federales (con las palabras Federal Credit Union en el nombre de la institución) Bancos acreditados a nivel estatal que no son miembros del Sistema de la Reserva Federal Office of Thrift Supervision Consumer Complaints Washington, DC National Credit Union Administration 1775 Duke Street Alexandria, VA Federal Deposit Insurance Corporation Consumer Response Center, 2345 Grand Avenue, Suite 100 Kansas City, Missouri Transportadores por aire, superficie o ferrocarril regulados por la antigua Junta de Aeronáutica Civil o por la Comisión Interestatal de Comercio Department of Transportation, Office of Financial Management Washington, DC Actividades sujetas a la Ley de Empacadores y Estibadores de 1921 Department of Agriculture Office of Deputy Administrator - GIPSA Washington, DC

12 NEW YORK DISCLOSURE AND RELEASE Current NY Residents Only In connection with (1) my application for medical staff privileges or allied health professional staff privileges, as the case may be, at any Banner Health facility, if I am seeking such privileges, (2) my application for employment (including contract for services) with Banner Health (including any affiliate of Banner Health), if I am seeking such employment, and/or (3) my request for recruitment assistance from a Banner Health facility, if I am seeking such assistance, I understand that consumer reports that may contain public record and investigative consumer information may be requested from Banner Health Secure Hire, 525 W. Brown Road, Suite 3318, Mesa, AZ Background screening reports may include: Employment verification (such as names of current and previous employers and dates of previous employment, reason for termination of employment, work experience, etc). I further understand that such reports may contain information concerning any criminal or civil records, educational achievements, professional license verification, driving record, credit report from federal, state and other agencies which maintain such records. I hereby consent to Banner Health Secure Hire obtaining the above information from such agencies. I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY BANNER HEALTH SECURE HIRE TO FURNISH THE ABOVE-MENTIONED INFORMATION. I have the right to request the nature and substance of all information obtained on my behalf by Banner Health Secure Hire including the sources of information; as well as the recipients of any reports on me the agency has previously furnished within the two (2) year period preceding my request. I understand that to initiate such request, I must contact Henrietta Williams, Director of Banner Health Secure Hire, at 525 W. Brown Road, Suite 3318, Mesa, AZ or via at or via toll free phone at I acknowledge that Banner Health Secure Hire will request and I must supply proper identification should such request be made. I hereby authorize procurement of consumer report(s). If I am granted medical staff privileges or allied health professional staff privileges, as the case may be, at any Banner Health facility, if I become employed by Banner Health (including any affiliate of Banner Health), or if I am receiving recruitment assistance from a Banner Health facility, this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports and investigative consumer reports at any time during the period that I have staff privileges at any Banner Health Facility, that I am employed by Banner Health (including any affiliate of Banner Health), or that I am receiving recruitment assistance from a Banner Health facility. I acknowledge receipt of a copy of Article 23-A of New York Correction Law. (The following information is requested for use in performing a background check on you and for no other purpose.) Print Name Social Security No. Date of Birth Applicant s Signature Date 12

13 -FOR CURRENT NY RESIDENTS ONLY- NEW YORK CORRECTION LAW ARTICLE 23-A A COPY OF THIS LAW IS BEING PROVIDED TO YOU IN CONJUNCTION WITH BANNER HEALTH INITIIATING A BACKGROUND SCREEN LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY New York Bus Code 380-c (b) (2) and 380-g (d) Section 750. Definitions. CONVICTED OF ONE OR MORE CRIMINAL OFFENSES For the purposes of this article, the following terms have the following meanings: 1) Public agency means the state or any local subdivision thereof, or any state or local department, agency, board or commission. (2) Private employer means any person, company, corporation, labor organization or association which employs ten or more persons. (3) Direct relationship means that the nature of criminal conduct for which the person was convicted has a direct bearing on his fitness or ability to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in question. (4) License means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions or instrumentalities as a condition for the lawful practice of any occupation, employment, trade, vocation, business, or profession. Provided, however, that license shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire any explosive, pistol, handgun, rifle, shotgun, or other firearm. (5) Employment means any occupation, vocation or employment, or any form of vocational or educational training. Provided, however, that employment shall not, for the purposes of this article, include membership in any law enforcement agency. 13

14 751. Applicability. The provisions of this article shall apply to any application by any person for a license or employment at any public or private employer, who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any license or employment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdiction preceded such employment or granting of a license, except where a mandatory forfeiture, disability or bar to employment is imposed by law, and has not been removed by an executive pardon, certificate of relief from disabilities or certificate of good conduct. Nothing in this article shall be construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with an application for employment made by a prospective employee or previously made by a current employee Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited. No application for any license or employment, and no employment or license held by an individual, to which the provisions of this article are applicable, shall be denied or acted upon adversely by reason of the individuals having been previously convicted of one or more criminal offenses, or by reason of a finding of lack of good moral character when such finding is based upon the fact that the individual has previously been convicted of one or more criminal offenses, unless: (1) There is a direct relationship between one or more of the previous criminal offenses and the specific license or employment sought or held by the individual; or (2) the issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk to property or to the safety or welfare of specific individuals or the general public Factors to be considered concerning a previous criminal conviction; presumption. 1. In making a determination pursuant to section seven hundred fifty two of this chapter, the public agency or private employer shall consider the following factors: (a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons previously convicted of one or more criminal offenses. (b) The specific duties and responsibilities necessarily related to the license or employment sought or held by the person. (c) The bearing, if any, the criminal offense or offenses for which the person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities. (d) The time which has elapsed since the occurrence of the criminal offense or offenses. (e) The age of the person at the time of occurrence of the criminal offense or offenses. (f) The seriousness of the offense or offenses. (g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct. 14

15 (h) The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of specific individuals or the general public. 2. In making a determination pursuant to section seven hundred fifty two of this chapter, the public agency or private employer shall also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein Written statement upon denial of license or employment. At the request of any person previously convicted of one or more criminal offenses who has been denied a license or employment, a public agency or private employer shall provide, within thirty days of a request, a written statement setting forth the reasons for such denial Enforcement. 1. In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to article seventy eight of the civil practice law and rules. 2. In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights pursuant to the powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city commission on human rights. 15

16 Driving records are valid for 30 days. I am requesting the following: STATE OF ALASKA REQUEST FOR DRIVING RECORD Driving Record (5 year / Insurance) X_ Driving Record (Full) I would like the record to be mailed or (faxed) to the address or fax number shown below. Your name, as shown on your Alaska license Your signature Telephone ( ) Fax(_480) Mailing address / / ALASKA Driver License Number OR Date of Birth AND Social Security Number Purpose of record: PRE EMPLOYMENT/PRE PLACEMENT Please complete the following when requesting information via fax. If your request is made by mail, include a check or money order payable to State of Alaska or DMV*. (*COMPLETE INFORMATION ABOVE THIS BOX ONLY*) MasterCard or Visa # Expiration Date / / Visa Security Code (3-digit number on back of card) Name as shown on card I understand that my credit card shown above will be charged $10.00 for each driving record requested. Signature Date / / (Signature of credit card holder.) FAX: MAIL: Division of Motor Vehicles (Valid for 90 days) ATTN: RESEARCH 1300 W. Benson Boulevard, Suite 200 Anchorage AK DMV USE ONLY $10 BATCH AMVC ID OFFICE FEE: CA CC CK Form 419F Rev. 01/01/

17 Washington State Department of Licensing Driving Record Request FOR VALIDATION ONLY You may use this form to request your driving record. We will mail, , or fax your record to you or to the individual or company you request below. Mail this request and $10 for each record in a check or money order payable to the Department of Licensing to: Driver Records Department of Licensing PO Box 9048 Olympia, WA Please allow two weeks for processing. If you have additional questions, contact customer service at (360) Requestor name (Last, First, Middle Initial) Washington driver license number Date of birth (Area code) Daytime telephone number Name of individual or company you want your drive record sent to: How would you like your driving record sent to you? (Check one only) U.S. mail Fax Delivery information (Mailing address, , or [Area code] Fax number) Type(s) of record Banner Health Secure Hire, Banner, Health Risk Management, 525 W Brown Rd, Suite 3318, Mesa AZ, 85201; Phone (480) Insurance records will show violations, convictions, and accidents only. Other drive records will show all traffic-related convictions, violations, collisions, suspensions, revocations, and disqualifications. We offer the following types of driving records. Check the box beside the type(s) you need. Noncommercial insurance record (3 year) Used to create and renew vehicle insurance policies. Commercial insurance record (3 year) Used to create and renew commercial vehicle insurance policies. Life insurance record (3 year) Used to create and renew life insurance policies. Employment record Used by employers to determine employment eligibility. Volunteer/ Transit record Used to determine if a volunteer driver meets the insurance and risk-managment requirements to drive a vanpool vehicle or should be permitted to operate a vehicle used to transport individuals who are under 18, over 65, or disabled. School bus driver record Used to determine if a person should be employed to operate a school bus. This request is to be billed and mailed to school district School district authorization Requestor code Complete record A complete driving record requested by the person named on the driving record. I declare under penalty of perjury under the laws of the state of Washington that I am the individual named above. X Date and Place Signature (valid for four months) DR (R/1/10)W The Department of Licensing has a policy of providing equal access to its services. If you need special accommodation, please call (360) or TTY (360)

18 -ATTACHMENT A- How to create your Banner Learning Center profile: NOTE: If you have created a student/instructor Banner Learning Center account in the past and cannot remember your login or password, DO NOT create another profile/account. or contact the Help Desk at (in Arizona) and (outside of Arizona) if you have any questions or concerns about your Banner Learning Center account. STEP 1. From any computer that has internet access type in: Enter the phrase [Banner learning center] in the Keyword box in upper right screen: STEP 2. Create a new account Select Students/Instructors select the [Click Here] link. 18

19 STEP 3. Complete information requested on the New User screen. YOU MUST complete all RED areas with an Asterisks * as shown above. Note: Additional Field Specific Instructions: Field Action A Employment Select Non Employee. B Personal Contact Type in your most frequently used address, contact phone number, address, city, state and zip code. Information C Division: Select Students and Interns Division, Corp. D Position: Select on the appropriate student or instructor position. E Hire Date: Enter the date you are creating this profile. F Social Security You may enter if you wish instead of your SSN Number (SSN) G School: Select on your school, select other if your school is not listed. H Username: Enter Username in the following format: first initial of first name + last name. Example: jdoe. The system will prompt you to add a number to the end if there is a duplicate. I Password: Create your own with a minimum of 6 alphanumeric characters. 19

20 STEP 4. Lastly, when you are completed, select on in the upper right hand corner. 20

Disclosure to Employment Applicant Regarding Procurement of a Consumer Report

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