(A conviction does not mean you will not be offered a volunteer position. What you
were convicted of, the circumstances surrounding the conviction and how long ago
the conviction occurred are important considerations in determining your eligibility.
Give all the facts so that a fair decision can be made.)
(Please note that hospitals ONLY allow next of kin to make decisions on your behalf)
Background Disclosure And Authorization Form
The Los Angeles County Fair Association (the Company) will procure a consumer report
and/or investigative consumer report on you in connection with your volunteer application
(including independent contractor assignments, as applicable). These background
reports may be obtained at any time after receipt of your authorization and, if
you are engaged by the Company, throughout your volunteer participation.
Intelius Screening Solutions LLC, a consumer reporting agency, will obtain the report
for the Company. Intelius Screening Solutions is located at 19800 North Creek Parkway,
Suite 200, Bothell, WA 98011, and can be reached at (866) 338-6739.
The report may contain information bearing on your character, general reputation,
personal characteristics, mode of living and credit standing. The types of information
that may be obtained include, but are not limited to: credit reports, social security
number verification, criminal records checks, public court records checks, driving
records checks, educational records checks, verification of employment positions
held, personal and professional references checks, and licensing and certification
checks. The information contained in the report will be obtained from private
and/or public record sources, including sources identified by you in your job application
or through interviews or correspondence with your past or present coworkers, neighbors,
friends, associates, current or former employers, educational institutions or other
This information is being collected to conduct the background screen on you. It
will not be used for any other purpose.
Provided to you with this authorization is a Summary of Your Rights Under the Fair Credit Reporting Act in a form prescribed by the Federal Trade Commission. Please do not sign this authorization
until you have received this summary.
You may request more information about the nature and scope of the background report
by contacting the Company.
California, Minnesota, and Oklahoma applicants only: check this box if you request
a copy of the report ordered on you.
Additional State Law Notice
If you are a California, Maine, New York, or Washington state applicant, employee,
or contractor, please also note:
CALIFORNIA: Pursuant to section 1786.22 of the California Civil
Code, you may contact Intelius Screening Solutions during normal business hours
(9am to 5pm PST, Monday through Friday) to obtain and review all information in
your file. You may obtain such information by appearing in person at Intelius Screening
Solutions’ offices, during normal business hours and upon reasonable notice,
and upon submitting proper identification and paying the costs duplication services.
You may be accompanied by one other person, provided that person furnishes proper
identification. You may also obtain a copy of your file by certified mail, if you
have previously provided identification in a written request that your file be sent
to you or a third party identified by you. You may also obtain a summary of your
file by telephone, upon providing proper identification. Intelius Screening Solutions
has trained personnel available to explain your file to you, including any coded
CALIFORNIA (En Espa'ol): De acuerdo con el art'culo
1786.22 del C'digo Civil, se puede llamar a Intelius Screening Solutions por los
horarios normales de trabajo (9 de la ma'ana a 5 de la tarde, tiempo del pac'fico,
lunes a viernes) para sacar y examinar su archivo privado en detalle. Para
conseguir una copia de su archivo privado, se puede hacer una visita en persona
a la oficina de Intelius Screening Solutions por los horarios normales de trabajo,
al darnos aviso razonable, al presentarnos de identificaci'n apropriada, y al pagarnos
las cuestas de duplicaci'n. Otra persona puede accompa'arle con tal que tambi'n
se traiga identificaci'n apropriada. Se puede pedirnos que le mandamos por correo
certificado una copia de su archivo privado con tal que hayamos recibido una solicitud
escrita que se lo mandemos una copia de su archivo privado a Usted o tal tercer
partido que est' identificado por Usted. Tambi'n se puede pedir por tel'fono
un resumen de su archivo privado, al presentarnos identificaci'n apropriada.
Empleamos trajabadores cualificados, a quienes est'n disponibles para explic'rselo
el contenido de su archivo privado con m's detalles, incluso algunos datos cifrados.
MAINE: You have the right, upon request, to be informed of whether
an investigative consumer report was requested, and if one was requested, the name
and address of the consumer reporting agency furnishing the report. You may request
and receive from the Company, within five business days of our receipt of your request,
the name, address, and telephone number of the nearest unit designated to handle
inquiries for the consumer reporting agency issuing an investigative consumer report
concerning you. You also have the right, under Maine law, to request and promptly
receive from all such agencies copies of any such reports.
NEW YORK: At the time you consent to your employer obtaining a
report you are entitled to receive a copy of Article 23-A of New York Correction
Law. Do not sign your consent until you receive a copy of that law.
WASHINGTON: If the Company requests and investigative consumer
report, you have the right, upon written request made within a reasonable period
of time after your receipt of this disclosure, to receive from the Company a complete
and accurate disclosure of the nature and scope of the investigation requested by
the Company. You also have the right to request from the consumer reporting agency
a written summary of your rights and remedies under the Washington Fair Credit Reporting
Background Screening Authorization
I have carefully read and understand this disclosure and authorization form and
I have received a copy of the “Summary of Your Rights Under the Fair Credit Reporting Act”
provided with this form. I have had the opportunity to review my rights. By my signature
below, I consent to the preparation of background reports by Intelius Screening
Solutions LLC, and to the release of such reports to the Company and its designated
representatives for the purpose of assisting the Company in making a determination
as to my eligibility for employment, promotion, retention, contract assignment or
for other lawful purposes.
I understand that, to the extent allowed by law, information contained in my job
application or otherwise disclosed to the Company by me before or during my employment
or contract assignment, if any, may be utilized for the purpose of obtaining such
consumer reports and/or investigative consumer reports about me. I understand that
nothing herein shall be construed as an offer of employment or contract for services.
I hereby authorize law enforcement agencies, learning institutions (including public
and private schools and universities), information service bureaus, credit bureaus,
record/data repositories, courts (federal/state/local), motor vehicle record agencies,
my past or present employers, the military, and other individuals or sources to
furnish any and all information on me that is requested by the consumer reporting
By my signature (including electronic) below, I certify the information provided
on and in connection with this form is true, accurate, and complete. I agree that
this form in original, faxed, photocopied or electronic form will be valid for any
background reports that may be requested by or on behalf of the Company.