Background Screening Notice Disclosure, and Authorization (E336)

BACKGROUND SCREENING NOTICE,

DISCLOSURE,AND AUTHORIZATION

Complete all applicable sections of this form.
Return the completed form to your Kelly representative as directed.

NOTICE AND DISCLOSURE

I have been notified that Kelly Services, Inc. (“Kelly”) may request that a background screening be conducted to verify any information I have provided in connection with my employment with Kelly Services or a customer of Kelly Services, or to determine my suitability for employment, retention, or reassignment.

Kelly may request a consumer report and/or an investigative consumer report in connection with my application for employment1 or at any time during my employment in accordance with all applicable laws. These reports may include information about my background, including but not limited to credit reports, criminal history records, court records, driving records, educational records, and/or employment records.

Upon written request to Kelly, I have the right to be informed when a consumer report or investigative consumer report is conducted, the nature and scope of the inquiry, and the name and address of the consumer reporting agency2 providing the report.

AUTHORIZATION

My signature below authorizes the procurement of a consumer report and/or investigative consumer report upon Kelly’s request in conjunction with my application for employment or during the course of my employment.3 The results of the reports may be shared among Kelly, its customer(s), and the reporting agency, when necessary, to determine my suitability for employment, retention, or reassignment.

If you are currently employed, may we contact your employer to verify employment? Yes No

Branch instructions: If the applicant checks No above, do not select the current employer when completing the request for a background screen.

I have read this Background Screening Notice, Disclosure, and Authorization, I understand it, and I agree to its terms4.

Full Legal Name (Printed)Last 4 digits of SocialSecurity No.

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SignatureDate

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Electronic Signature*Date

*If you are submitting this form electronically, type your name on the Electronic Signature line and check the box to the right next to “I agree.”This is your electronic signature. By electronically signing this form, you agree that you have reviewed this entire form and agree to all the terms contained in it. / I agree.

1 Applicants in Hawaii: a background screening will only be conducted after an offer of employment.

2 Applicants in California: the consumer reporting agency used to provide the report is:

Verifications, Inc., 6900 Wedgwood Road North, Suite 120, Minneapolis, MN55311

3 Applicants in California, Minnesota, and Oklahoma:

By checking this box, I request a free copy of any consumer report from the consumer reporting agency at the same time the report is provided to Kelly.

4 Applicants in New York:

By checking this box, I acknowledge that I have received a copy of New York Article 23-A.