Fair Credit Reporting Act Disclosure

FAIRCREDITREPORTINGACTDISCLOSUREANDAUTHORIZATIONTORELEASEINFORMATION

DISCLOSURE

InconnectionwithyourapplicationforemploymentattheUniversityofTennessee,theUniversitymayverifyinformationwithintheapplicationorothermaterialsrelatingtoyourapplicationforemployment.Aspartofthatverificationprocess,theUniversitywillrequest,fromabackgroundcheckvendor,aninvestigativeconsumerreport(“BackgroundCheckReport”)onyouasdefinedintheFairCreditReportingAct.

ForUniversitypurposes,aBackgroundCheckReportwillconsistofacriminalbackgroundcheck,employmentverification,educationverification,referencecheck,publicrecordscheck,drivingrecordscheck,andprofessionallicensecheck.Itwillnotincludeacreditcheck,althoughinformationthatpertainstoyourcreditmaybecontainedamongpublicrecords(i.e.,bankruptcyfilings).TheinformationobtainedintheBackgroundCheckReportwillbeutilizedonlyduringtheinitialemploymentapplicationprocess.Intheeventthatinformationfromthereportisutilizedinwholeorinpartinmakinganadversedecision,beforemakingtheadversedecision,wewillprovidetoyouacopyoftheBackgroundCheckReportandadescriptioninwritingofyourrightsundertheFairCreditReportingAct,15U.S.C.§1681etseq.

AUTHORIZATION

Bymysignaturebelow,IexpresslyauthorizeandinstructthebackgroundcheckvendortoperformandreleasetotheUniversityaBackgroundCheckReportonmeattherequestoftheUniversityinconjunctionwithmyjobapplication.Iunderstandthat,totheextentallowedbylaw,informationcontainedinmyjobapplicationorotherwisedisclosedbyme,ifany,maybeusedforthepurposeofconductingabackgroundcheck.

Bymysignaturebelow,IalsoauthorizethedisclosuretotheUniversityand/ortothebackgroundcheckvendorofinformationconcerningmyemploymenthistory,earninghistory,education,motorvehiclehistoryandstanding,criminalhistory,andallotherpubliclyavailableinformationtheUniversitydeemspertinentbyanyindividual,corporationorotherprivateorpublicentity,includingwithoutlimitationthefollowing:employers;learninginstitutions,includingcollegesanduniversities;lawenforcementagencies;federal,stateandlocalcourts;themilitary;motorvehiclerecordsagencies;andotherpublicsources.IherebyreleaseandholdthebackgroundcheckvendorandtheUniversity,itsofficers,directors,employees,andtrusteesharmlessfromanyandallliabilitywithrespecttotheBackgroundCheckReport,investigations,verifications,and/ortheuseofanyinformationrelevanttomyemployment.

Bymysignaturebelow,IacknowledgethatthisAuthorizationForm,inoriginal,faxed,photocopiedorelectronicform,willbevalidforanyreportsthatmayberequestedbytheUniversityofTennessee.

SignatureofApplicant:Date:

PrintFullName:SocialSecurity#:--

PrintOtherNamesUsed(alias,maiden,nickname)

PrintFather’sFullName(internationalemployees)

PrintMother’sMaidenName(internationalemployees)

PrintGovernmentID#(internationalemployees)

PrintPassport#(internationalemployees)

PrintDriver’sLicenseNumber

StateIssued

DateofBirth://

PrintCurrentResidenceAddress:(NumberStreet) City State Zip

ListallResidenceAddressesinPastSevenYears(attachadditionalsheetsifnecessary)

(Datefrom–to)(NumberStreet)CityState/ProvinceZip

_(Datefrom–to) (NumberStreet) City State/Province Zip

PLEASESUPPLYTHEFOLLOWINGSCHOOLINFORMATION(HIGHESTDEGREEEARNED):N/A□

SCHOOL:

CITY/STATE:

DEGREE:

DEGREESTATUS:

DATESATTENDED:

(StartMonth/Year)(EndMonth/Year)

ADDITIONALSTATELAWNOTICES

ForMaineApplicantsOnly

Uponrequest,youwillbeinformedwhetherornotaninvestigativeconsumerreportwasrequested,andifsuchareportwas

requested,thenameandaddressoftheconsumerreportingagencyfurnishingthereport.Youmayrequestandreceivefromus,within5businessdaysofourreceiptofyourrequest,thename,addressandtelephonenumberofthenearestunitdesignatedtohandleinquiriesfortheconsumerreportingagencyissuinganinvestigativeconsumerreportconcerningyou.Youalsohavetheright,underMainelaw,torequestandpromptlyreceivefromallsuchagenciescopiesofanyreports.

ForNewYorkApplicantsOnly

Youhavetheright,uponwrittenrequest,tobeinformedofwhetherornotaconsumerreportwasrequested.Ifaconsumer

reportisrequested,youwillbeprovidedwiththenameandaddressoftheconsumerreportingagencyfurnishingthereport.

ForCaliforniaApplicantsOnly

YoumayviewthefilemaintainedonyoubyTrueScreenduringnormalbusinesshours.Youmayalsoobtainacopyofthisfileuponsubmittingproperidentificationandpayingthecostsofduplicationservices,byappearingatTrueSCreen’soffices

inperson,duringnormalbusinesshoursandonreasonablenotice,orbymail;youmayalsoreceiveasummaryofthefilebytelephone.TrueScreenhastrainedpersonnelavailabletoexplainyourfiletoyou,includinganycodedinformation.Ifyouappearinperson,youmustbeaccompaniedbyoneotherperson,providedthatpersonfurnishesproperidentification.

ForMinnesota,OklahomaandCaliforniaApplicantsOnly:Inconnectionwithyourapplicationforemployment,yourinvestigativeconsumerreportmaybeobtainedandreviewed.UnderCalifornia,MinnesotaandOklahomalaw,youhavearighttoafreecopyofyourinvestigativeconsumerreportbycheckingtheappropriateboxbelow.

YES,IamaCaliforniaresidentandwouldlikeafreecopyofmyinvestigativeconsumerreport.

YES,IamaMinnesotaresidentandwouldlikeafreecopyofmyconsumerreport.

YES,IamanOklahomaresidentandwouldlikeafreecopyofmyconsumerreport.