P.O. Box 539
Denver, Colorado 80201-0539
Telephone 303.839.5177
Toll Free 800.884.1328 / VERIFICATION ORDER FORM
Print Clearly
Member Name
High Plains Library District
(formerly Weld Library District) / Member #
69223
Member Mailing Address
City/State/Zip / 1939 61st Avenue
Greeley, CO 80634
Attention
Becky Becker / E-mail address

Phone
970.506.8590 / Fax
970.506.8551 / Date sent
to MSEC
Upon completion of report
please check preference / email mail call fax

Note: Orders received after three p.m. will be treated as next day business.

Search can be done using current or other name(s) previously used, such as maiden names, aliases and nicknames. Under what name(s) should the search be done? / Date of Birth
Social Security Number
Telephone
Applicants Current Address
City/State/Zip
Job Applied For
Drivers License Number / Type / State
Attached with this request: Disclosure & Authorization Application Other:

PLEASE CHECK BOX FOR REQUESTED SCREENINGS

A / Seven Year Colorado Criminal*
Excludes Denver County Misdemeanor / G / Education Verification
B / Seven Year Denver County Misdemeanor Only
C / Seven Year Other State Criminal - search is done on an individual county basis*
List city & state / H / Motor Vehicle*
State Lic. #
State Lic. #
D / Seven Year Federal Criminal*
List city & state / I / Employment, In-depth
J / Personal References
1 2
3 4
E / Employment Verification
3 jobs or 5 years
F / Trak Report / K / Other

Incomplete information may result in a report delay.* Birthdate needed to confirm identity
** Minimum order charge $18

Permission for Release of Records

Record information available at Drivers License offices and 1881 Pierce St.

All other requests available only at 1881 Pierce St., Lakewood, CO.

I hereby authorize the release of records maintained by the Colorado Department of Revenue, Motor Vehicle Division pursuant to the Driver’s Privacy Protection Act (18 USC 2721) and Colorado law (42-72-204, 42-1-206, 42-3-125 CRS).

Printed Name:______

Signature:______Date:______

Date of Birth:______Driver’s License number:______

Purpose for which records are released:__Employment ______

Requestor’s Name: Deborah Dale Brackney______

Company: Mountain States Employers Council______

Address: 1799 Pennsylvania Street______

City: Denver______State: Colorado______Zip code: 80201_____

FAIR CREDIT REPORTING ACT DISCLOSURE & AUTHORIZATION

DISCLOSURE

As an applicant for employment or volunteering or a current employee or volunteer of High Plains Library District, you are a consumer with rights under the Fair Credit Reporting Act. When any of the following circumstances exist, High Plains Library District may choose to obtain and use information contained in either a consumer report or an investigative consumer report from a consumer reporting agency about you when: (1) considering your application for employment or volunteering, (2) making a decision whether to offer you employment or a volunteer position, (3) deciding whether to continue your employment (if you are hired) or volunteer position (if you are selected), or (4) making other employment-related or volunteer-related decisions directly affecting you.

For explanation purposes, a consumer reporting agency is a person or business which, for monetary fees, dues, or on a cooperative nonprofit basis, regularly assembles or evaluates consumer credit information or other information on consumers for the purpose of furnishing consumer reports to others, such as High Plains Library District.

A consumer report means any written, oral or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in establishing your eligibility for employment purposes.

An investigative consumer report means a consumer report or portion thereof in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your neighbors, friends, or associates reported on or with others with whom you are acquainted or who may have knowledge concerning any such items of information.

In the event an investigative consumer report is prepared, you may request additional disclosures regarding the nature and scope of the investigation requested as well as a written summary of your rights under the Fair Credit Reporting Act.

AUTHORIZATION

By signing below, I,______, hereby voluntarily authorize

High Plains Library District to obtain either a consumer report or an investigative consumer report about me from a consumer reporting agency and to consider this information when making decisions regarding my employment/volunteering at High Plains Library District. I understand that I have rights under the Fair Credit Reporting Act, including the rights discussed above. This report may be delivered in either written or electronic form.

(If a minor under age 18, signature must be accompanied by parent’s or legal guardian’s signature)

______

NameDate Signed

______

Social Security # Date of Birth

______

Parent’s or Legal Guardian’s Signature (if required)Date Signed

09/02