I hereby authorize the Medina County District Library or any of its authorized representatives to perform a check of my background, including criminal record, past employment, education, volunteer history and/or any other references which the Library or its representatives consider relevant for the purpose of verifying such information as I have provided with respect to my application for volunteer assignment and to obtain from such sources any references which the Library or its representatives believe are appropriate for the volunteer position I have requested.

I understand that upon request I may inspect any information obtained through such reference check as above described and do further understand that such information shall, to the extent permissible by law, be kept confidential by the Medina County District Library and its authorized representatives.

I understand that refusal to agree to a background check will exclude me from consideration for any volunteer positions.

I hereby authorize and encourage those individuals or organizations contacted for the pupose of a background check to disclose to the Medina County District Library their full and honest evaluation of my suitability of the described volunteer work and such other information as they deem appropriate. I release all parties from any possible damage claims from disclosing or receiving such information.

I acknowledge that I have read, understand and, by virtue of my signature below, agree to the above.
 

_______________________________________
Volunteer Applicant’s Name (printed)

_______________________________________
Volunteer Applicant’s Signature

_______________________________________
Date

_______________________________________
Social Security Number

Acknowledgment And Authorization For Background Check

I acknowledge receipt of the separate documents entitled Disclosure Regarding Background Investigation, Disclosure Regarding “Investigative Consumer Report” Background Investigation, And A Summary Of Your Rights Under The Fair Credit Reporting Act and certify that I have read and understand all of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by Medina County District Library (“Employer”) at any time after receipt of this authorization and throughout my employment, if applicable. To this end, 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, or insurance company to furnish any and all background information requested by Corporate Screening, 16530 Commerce Court, Cleveland, Ohio 44130-6305; Tel. # 800-229-8606; www.corporatescreening.com and/or Employer. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

First Name ___________________________ Last Name ________________________________

Driver’s License Number _____________________ State Issued _____________________

Social Security Number _____________________

Current Address _________________________________________

City _________________________________________

State ______________ Zip _____________

Email ____________________________________


Signature ________________________________________________

Date ____________________________

Disclosure Regarding Background Investigation

Medina County District Library (“the Company”) may obtain information about you from a third party consumer reporting agency for employment purposes (including independent contractor or volunteer assignments, as applicable). Thus, you may be the subject of a “consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment history, or other background checks. You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you and to request a copy of your report. These searches will be conducted by Corporate Screening, 16530 Commerce Court, Cleveland, Ohio 44130-6305; Tel. # 800-229-8606; www.corporatescreening.com.

Name (please print): _______________________________

Signature: _______________________________

Date: _______________________________

Disclosure Regarding “Investigative Consumer Report” Background Investigation

Medina County District Library (the “Company”), to which you have applied for employment, may request an investigative consumer report about you from a third party consumer reporting agency, in connection with your employment or application for employment (including independent contractor or volunteer assignments, as applicable) and throughout your employment if you are hired or retained. An “investigative consumer report” is a background report that includes information from personal interviews (except in California, where that term includes background reports with or without information obtained from personal interviews). The most common form of an investigative consumer report in connection with your employment is a reference check through personal interviews with sources such as your former employers and associates, and other information sources. The investigative consumer report may contain information concerning your character, general reputation, personal characteristics and mode of living. You may request more information about the nature and scope of an investigative consumer report, if any, by contacting the Company. You have the right, upon written request made within a reasonable time, to request (1) whether an investigative consumer report has been obtained about you, (2) disclosure of the nature and scope of any investigative consumer report and (3) a copy of your report. These reports will be conducted by Corporate Screening, 16530 Commerce Court, Cleveland, Ohio 44130-6305; Tel. # 800-229-8606; www.corporatescreening.com.

Name (please print): _______________________________

Signature: _______________________________

Date: _______________________________

Para información en espanol, visite www.consumerfmance.gov/learnmore. o escribe a la Consumer Financial Protection Bureau, 1700 G Street N. W. , Washington, DC 20552.

A Summary of Your Rights Under the Fair Credit Reporting Act

1. Type of Business:

   • Banks, savings associations, and credit unions with total assets of over $ 10 billion and their affiliates
   • Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the CFPB:

   Contact:

   • Consumer Financial Protection Bureau
     1700 G Street, N. W.
     Washington, DC 20552
   • Federal Trade Commission
     Consumer Response Center
     600 Pennsylvania Avenue, N.W.
     Washington, DC 20580
     (877) 382-4357

2. To the extent not included in item 1 above

   • National banks, federal savings associations, and federal Customer branches and federal agencies of foreign banks
   • State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and Insured State Branches of Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act.
   • Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations
   • Federal Credit Unions

   Contact:

   • Office of the Comptroller of the Currency
     Customer Assistance Group
     1301 McKinney Street, Suite 3450
     Houston, TX 77010-9050
   • Federal Reserve Consumer Help Center
     P.O. Box 1200
     Minneapolis, MN 55480
   • FDIC Consumer Response Center
     1100 Walnut Street, Box # 11
     Kansas City, MO 64106
   • National Credit Union Administration
     Office of Consumer Financial Protection (OCFP)
     Division of Consumer Compliance Policy and Outreach
     177 5 Duke Street
     Alexandria, VA 223 14
3. Air carriers

Contact:

Asst. General Counsel for Aviation Enforcement & Proceedings
Aviation Consumer Protection Division
Department of Transportation
1200 New Jersey A venue, S. E.
Washington, DC 20590

1. Creditors Subject to the Surface Transportation Board

Contact:

• Office of Proceedings, Surface Transportation Board
  Department of Transportation
  395 E Street, S.W.
  Washington, DC 20423

1. Creditors Subject to the Packers and Stockyards Act, 1921

Contact:

• Nearest Packers and Stockyards Administration area supervisor

1. Small Business Investment Companies

Contact:

• Associate Deputy Administrator for Capital Access
  United States Small Business Administration
  409 Third Street, S.W. , Suite 8200
  Washington, DC 20416

1. Brokers and Dealers

Contact:

• Securities and Exchange Commission
  I 00 F Street, N.E.
  Washington, DC 20549

1. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations

Contact:

• Farm Credit Administration
  1501 Farm Credit Drive
  McLean, VA 22102-5090

1. Retailers, Finance Companies, and All Other Creditors Not Listed Above

Contact:

• Federal Trade Commission
  Consumer Response Center
  600 Pennsylvania Avenue, N.W.
  Washington, DC 20580
  (877) 382-4357