Background Disclosure and Authorization - Acknowledgement and Authorization - Background Check Form

Sep 17, 2026

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Background Disclosure and Authorization document for employment, contract, or volunteer purposes, authorizing Central Piedmont to obtain consumer reports and investigative consumer reports from third-party consumer reporting agencies. It explains that reports may include credit history, criminal history, social security verification, motor vehicle records, and education or employment verification, as permitted by law. It includes applicant acknowledgment of receipt of the Fair Credit Reporting Act summary and consent to background checks, outlines the consequences of inaccurate disclosure, and collects signature and personal background details.

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Pages7

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Background Disclosure and Authorization

Acknowledgement and Authorization

Felony/Misdemeanor Question

Personal Information and Addresses

Summary of Your Rights Under the Fair Credit Reporting Act

Background Disclosure and Authorization Central Piedmont may obtain information about you for employment, contract or volunteer purposes from a third party consumer reporting agency. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records, verification of your education or employment history, or other background checks. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment or for volunteer purposes is an investigation into your criminal history conducted by CastleBranch, 1845 Sir Tyler Drive, Wilmington, NC 28405, 888.666.7788, or another outside organization. The scope of this notice and authorization is all-encompassing allowing Central Piedmont to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law. Acknowledgement and Authorization I acknowledge receipt of the Background Disclosure and Authorization 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 Central Piedmont 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, information service bureau or employer to furnish any and all background information requested by CastleBranch, 1845 Sir Tyler Drive, Wilmington, NC 28405, 888.666.7788, another outside organization acting on behalf of Central Piedmont, and/or Central Piedmont itself. I also understand that the information I provide regarding my sex, race and date of birth will be used for the sole purpose of gathering the above information correctly, and will not be used to discriminate against me in violation of any law. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original. I further acknowledge that any offer of employment that I have received is conditioned upon the successful completion of the background check, and any relevant criminal convictions and/or failure to truthfully and fully disclose those convictions on this form may result in Central Piedmont rescinding my conditional offer of employment. Signature: Printed Name: Date 1 Have you been convicted of a felony or a misdemeanor in the last seven (7) years? This includes DUI/DWI, worthless checks, violations of local ordinances or state statutes that resulted in a fine or incarceration, misdemeanors, felonies, etc. Guilty verdicts, guilty pleas, prayers for judgement (PJC) and “no contest”pleas must be included unless the convictions have been expunged from your record. (Check Answer) Yes No If you answered Yes to any of the questions, provide city, county, and state of conviction and date and nature of the offense, along with sentencing information. Also provide any other information you would like Central Piedmont to consider. Enter NA if you answered No and this question does not apply to you. | | | --- | | | | | | | | | | | Signature: Printed name: Date: 2 Please provide the following information. It will be used solely in gathering information for the background investigation and will not be used to discriminate in violation of any law. Name: Last Name, First Name, Middle Name Other Names (Maiden, Aliases): SSN: Date of Birth: Gender: Male Female Ethnicity (optional): Hispanic/Latino Non-Hispanic/Latino Race (optional): American Indian/Alaskan Native Asian White Black/African American Hawaiian/Pacific Islander List all add

FAQs

What information can Central Piedmont obtain for the background check?

Central Piedmont may obtain consumer reports and investigative consumer reports that can include credit history, criminal history, social security verification, motor vehicle records, and verification of education or employment history, as permitted by law.

What does signing this authorization allow?

By signing, the applicant authorizes Central Piedmont to obtain consumer reports and/or investigative consumer reports at any time after receipt and during employment, and authorizes third parties and agencies to furnish background information requested.

What happens if I received a conditional offer and the background check is not completed successfully?

Any offer of employment is conditioned on successful completion of the background check. Relevant criminal convictions and/or failure to truthfully and fully disclose convictions on the form may lead to Central Piedmont rescinding the conditional offer.

Sep 17, 2026

Upload by Blaney