District Consent Form

Access a District Consent Form.


During the application process and at any time during the tenure of my employment/service with The Company, [Rotary District 5160] , I hereby authorize ChoicePoint Services Inc., on behalf of The Company to procure a consumer report (known as an investigative consumer report in California) which I understand may include information regarding my character, general reputation, or personal characteristics.  This report may be compiled with information from courts record repositories, departments of motor vehicles, past or present employers and educational institutions, governmental occupational licensing or registration entities, business or personal references, and any other source required to verify information that I have voluntarily supplied. I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification, to the extent such investigation includes information bearing on my character, general reputation, or personal characteristics.

 ____________________            ______________________

Applicant/Employee Signature                         Date

 ________-_____-_________    ______________________

Social Security Number *            Date of Birth*                          


 * For identification purposes only

MN & Oklahoma Residents please note: In connection with your application for employment/service, your consumer report may be obtained and reviewed.  Under Minnesota and Oklahoma law, you have a right to receive a free copy of your consumer report by checking the appropriate box below.

 ___ YES, I am a Minnesota resident and would like a free copy of my consumer report.

___ YES, I am an Oklahoma resident and would like a free copy of my consumer report.

 CA Residents please note: Under CA law, you have a right to receive a free copy of your report by checking the appropriate box below.

 ___ YES, I am a California resident and would like a free copy of my investigative consumer report.

Printed Name ________________________________

 Street Address________________________________

 City, State, Zip _______________________________

 Rotary Club I am affiliated with: ___________________



Thomas R. Port, 83 Mission Hills St., Oakland, CA 94605         tport@earthlink.net





This is used to inform you that a consumer report is being obtained from a consumer reporting agency for the purpose of evaluating you for employment, volunteer service or a contracted position, including retention as an employee, volunteer or independent contractor.


This report may contain information bearing on your character, general reputation, and personal characteristics from public or private record sources.


California Notice:

You have the right under Section 1786.22 of the California Civil Code to contact ChoicePoint during normal business hours to obtain your file for your review. You may obtain such information as follows:


1. In person at ChoicePoint’s office at the address listed above. You will need to furnish proper identification prior to receiving your file. You may have someone accompany you and should inform such person that they will also have to present reasonable identification. If you want ChoicePoint to disclose to or discuss your information with this third party, you may be required to provide a written statement granting ChoicePoint permission to do so.


2. By certified mail, if you make a written request (and provide proper identification) to have your file sent to a specified addressee.


3. By telephone, if you have previously made a written request and provided proper identification.


ChoicePoint has trained personnel to explain any information that is furnished to you and to explain any information that is coded.


Employer please note: If consumer checks “YES” regarding the full consumer report, and consumer resides in California, you will need to provide the individual with a copy of their consumer report.