Background Check Authorization


ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK

I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Health Rosetta Group PBC (“the Company”) at any time after receipt of this authorization and throughout my employment or volunteer placement, 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 the following two organizations.

  1. Asurint, P.O. Box 14730, Cleveland, OH 44114, 800-906-1674, www.asurint.com
  2. The National Insurance Producer Registry,1100 Walnut Street, Suite 1500, Kansas City, Missouri 64106, www.nipr.com.

I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.  

New York applicants only: Upon request, you will be informed whether or not a consumer report was requested by the Company, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report.   You have the right to inspect and receive a copy of any investigative consumer report requested by the Company by contacting the consumer reporting agency identified above directly. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law

Washington State applicants only: 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 Act.

Minnesota and Oklahoma applicants only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company.

 

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Signature Certificate
Document name: Background Check Authorization
lock iconUnique Document ID: 29e0dd5c57030b62b27ab5343c5afb11db1df51b
Timestamp Audit
August 23, 2017 2:42 pm PSTBackground Check Authorization Uploaded by Sean Schantzen - contact@healthfundr.com IP 12.37.157.26
August 23, 2017 3:02 pm PSTMelissa Taylor - melissa@healthrosetta.org added by Sean Schantzen - sean@healthrosetta.org as a CC'd Recipient Ip: 72.214.133.227
August 23, 2017 3:08 pm PSTMelissa Taylor - melissa@healthrosetta.org added by Sean Schantzen - sean@healthrosetta.org as a CC'd Recipient Ip: 72.214.133.227
August 23, 2017 3:10 pm PSTMelissa Taylor - melissa@healthrosetta.org added by Sean Schantzen - sean@healthrosetta.org as a CC'd Recipient Ip: 72.214.133.227
August 23, 2017 3:12 pm PSTMelissa Taylor - melissa@healthrosetta.org added by Sean Schantzen - sean@healthrosetta.org as a CC'd Recipient Ip: 72.214.133.227
September 21, 2017 3:17 pm PSTMelissa Taylor - melissa@healthrosetta.org added by Sean Schantzen - sean@healthrosetta.org as a CC'd Recipient Ip: 98.189.61.213
September 21, 2017 3:17 pm PSTRobin Schantzen - robin@22counsel.com added by Sean Schantzen - sean@healthrosetta.org as a CC'd Recipient Ip: 98.189.61.213
July 16, 2018 1:25 pm PSTMelissa Taylor - melissa@healthrosetta.org added by Sean Schantzen - contact@healthfundr.com as a CC'd Recipient Ip: 12.37.157.26
July 16, 2018 1:25 pm PSTRobin Schantzen - robin@22counsel.com added by Sean Schantzen - contact@healthfundr.com as a CC'd Recipient Ip: 12.37.157.26