Required Employment Forms

Name of Agency & Region: JOURNEYS IN COMMUNITY LIVING, MIDDLE TN REGION

As part of our procedure for processing your application for employment for a position involving direct contact with or responsibility for persons with disabilities and aging, we must inform you that a criminal background check will be conducted if you are to be employed by Journeys in Community Living.

All job applicants for positions relating to the direct contact with or responsibility for persons with disabilities and aging must disclose information on any prior conviction(s) by any local, state, federal or military court of any felony or any other conviction involving sexual crimes.

You must list below any felony or any other conviction involving sexual crimes, including, but not limited to:

• rape, sexual assault, sexual battery, exhibitionism, voyeurism, or an attempt to commit any of such sexual crimes
• homicide or attempted homicide
  
  
• felonious assault or attempted felonious assault
  
  
• unlawful breaking or entering
  
  
• robbery
  
  
• burglary
  
  
• theft
  
  
• arson

If you are required to register or have registered with the registry of sexual offenders in accordance with Tennessee Code Annotated, Section 36-6-110, you must disclose such information.

Forms/Doc/Applicant Release of Information/ Criminal Background check

5/25

JOURNEYS IN COMMUNITY LIVING, the “Company," may request an investigative consumer report about you from a third party consumer reporting agency, in connection with your employment or application for employment. An "investigative consumer report" is a background report that includes information from personal interviews (except in California, where that term includes background reports with or without information obtained from personal interviews The most common form of an investigative consumer report in connection with your employment is a reference check through personal interviews with sources such as your former employers and associates, and other information sources. The investigative consumer report may contain information concerning your character, general reputation, personal characteristics, mode of living, or income verification. You may request more information about the nature and scope of an investigative consumer report, if any, by contacting the Company.

I acknowledge receipt of the separate documents entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION, A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and the DISCLOSURE FOR INVESTIGATIVE CONSUMER REPORT and certify that I have read and understand those documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" by the Company 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 (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by JD Palatine, LLC dba JDP, 855-940-3232, 10675 Perry Hwy #607, Wexford, PA 15090, jdp.com and/or Company itself. I agree that a facsimile ("fax"), electronic or photographic copy of this Authorization shall be as valid as the original.

I understand that by signing below, that by doing so:

• I am authorizing JD Palatine LLC, dba JDP to conduct the background check(s) described above
• I acknowledge I may request a hard copy of this Disclosure and Authorization form after agreeing to the background check electronically by calling JD Palatine LLC, dba JDP at 855-940-3232.

I certify that all elements of the personal data I have provided are true, accurate and complete.

Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records Here is a summary of your major rights under FCRA. For more information, including information about additional rights, go to

www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

• You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.
• You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure” You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if: oa person has taken adverse action against you because of information in your credit report; oyou are the victim of identity theft and place a fraud alert in your file; oyour file contains inaccurate information as a result of fraud; oyou are on public assistance; oyou are unemployed but expect to apply for employment within 60 days. In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.
• You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.
• You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.
• Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete, or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.
• Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.
• Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need – usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.
• You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.
• You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address form the lists these offers are based on. You may opt out with the nationwide credit bureaus at 1-888-5-
• The following FCRA right applies with respect to nationwide consumer reporting agencies:

You have a right to place a "security freeze" on your credit report, which will prohibit a consumer reporting agency from releasing information in your credit report without your express authorization. The security freeze is designed to prevent credit, loans, and services from being approved in your name without your consent. However, you should be aware that using a security freeze to take control over who gets access to the personal and financial information in your credit report may delay, interfere with, or prohibit the timely approval of any subsequent request or application you make regarding a new loan, credit, mortgage, or any other account involving the extension of credit. As an alternative to a security freeze, you have the right to place an initial or extended fraud alert on your credit file at no cost. An initial fraud alert is a 1-year alert that is placed on a consumer’s credit file. Upon seeing a fraud alert display on a consumer’s credit file, a business is required to take steps to verify the consumer’s identity before extending new credit. If you are a victim of identity theft, you are entitled to an extended fraud alert, which is a fraud alert lasting 7 years. A security freeze does not apply to a person or entity, or its affiliates, or collection agencies acting on behalf of the person or entity, with which you have an existing account that requests information in your credit report for the purposes of reviewing or collecting the account. Reviewing the account includes activities related to account maintenance, monitoring, credit line increases, and account upgrades and enhancements.

• You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.
• Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact:

The information we request from your previous employer(s) includes the following:

• Title of position applicant was hired or title of position when applicant left.
  
  
• Employment dates (from - to).
• Hours per week applicant worked.
  
  
• Reason applicant left employment with company.
  
  
• Would you rehire? If no, why?
  
  
• Additional comments.