Dear Candidate,

You have been asked to complete this form as a part of your hiring process. Prior to being asked to complete this form, you should have received the following two (2) documents regarding your rights regarding background checks as a condition of employment:

1. A Summary of Your Rights Under the Fair Credit Reporting Act, and

2. New York Correction Law Article 23-A: Licensure and Employment Of Persons Previously Convicted Of One Or More Criminal Offenses.

Before you can request a background check, you must acknowledge that you have received, read and understand the aforementioned documents, and that you have signed the acknowledgement and request authorization form. If you have not been given these documents, please exit this form and request them from your hiring contact. Your background check request will not be processed without this acknowledgement.

Please contact your hiring representative or the WPV office at 585-568-8340 if you need assistance completing this form.

Best of wishes for your future employment.

ACKNOWLEDGEMENT

Select the box below to acknowledge that you have received, reviewed and understand the documents listed above.

Yes, I have received, reviewed and understand the documents listed above.

YOUR INFORMATION

Your name

Include middle name or initial if available

First Name

Last Name

Your Address (no PO boxes)

Street, City, State, ZIP

Social Security Number

Your date of birth

YYYY

NOT COMMON: If your employer requires a DMV check enter your license number and state.

Only enter this information if your employer informed you they will be running a DMV check.

Best number to reach you

(###)

###

####

Your email

Confirm email

EMPLOYER INFORMATION

What is the name of your potential employer?

Which location?

Who is your hiring contact?

OTHER/COMMENTS

Is there anything else you'd like to add?

DIGITAL SIGNATURE

By typing your name below, you certify that all information is true and correct to the best of your knowledge.

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