DISCLOSURE REGARDING BACKGROUND REPORT
Interim Physicians, LLC. (the “Company”) will procure a consumer report and/or investigative consumer report on you in connection with your application for contract position purposes (including employment, volunteer, or independent contractor assignments, as applicable) as defined under the Fair Credit Reporting Act. These background reports may be obtained at any time after receipt of your authorization and, if you are hired or engaged by Interim Physicians, LLC., throughout your contract period.
SterlingONE LLC, a consumer reporting agency, will obtain the report for Interim Physicians, LLC. SterlingONE is located at 19800 North Creek Parkway, Suite 200, Bothell, WA 98011, and can be reached at (866) 338-6739.
The report may contain information bearing on your character, general reputation, personal characteristics, mode of living. The information that may be included in your report include: social security number trace, criminal records checks, public court records checks, driving records checks, educational records checks, verification of employment positions held, personal and professional references checks, and licensing and certification checks. The information contained in the report will be obtained from private and/or public record sources. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for contract position is an investigation into your education and/or employment history.
To view a summary of your rights under the Fair Credit Reporting Act, visit:
I have carefully read and understand this disclosure and authorization form and I have received a copy of the Summary of Your Rights Under the Fair Credit Reporting Act provided with this form. I have had the opportunity to review my rights. By my signature below, I consent to the preparation of background reports by SterlingONE LLC, and to the release of such reports to Interim Physicians, LLC and its designated representatives for the purpose of assisting Interim Physicians, LLC in making a determination as to my eligibility for contract employment, contract assignment or for other lawful purposes.
I understand that I may be the subject of an investigative consumer report which may include information regarding my background. By my signature below, I consent to the preparation of background reports by SterlingONE, and to the release of such reports to Interim Physicians, LLC and its designated representatives for the purpose of assisting Interim Physicians, LLC in making a determination as to my eligibility for contract assignments.
I understand that, to the extent allowed by law, information contained in my job application or otherwise disclosed to Interim Physicians, LLC by me before or during my contract assignment, if any, may be utilized for the purpose of obtaining such consumer reports and/or investigative consumer reports about me. I understand that nothing herein shall be construed as an offer of a contract for services. I hereby authorize law enforcement agencies, learning institutions(including public and private schools and universities), information service bureaus, record/data repositories, courts(federal/state/local), motor vehicle record agencies, my past or present employers, the military and other individuals or sources to furnish any and all information on me that is requested by the consumer reporting agency. By my signature (including electronic) below, I certify the information provided on and in connection with this form is true, accurate, and complete. I agree that this form in original, faxed, photocopied or electronic form will be valid for any background reports that may be requested by or on behalf of Interim Physicians, LLC.
This information is being collected to conduct the background screen on you. It will not be used for any other purpose.