Date
submitted _______
Report
Received______
The Federal Fair Credit Reporting
Act provides that anyone who knowingly and willfully obtains information on a
consumer from a consumer reporting agency under false pretenses shall be liable
for the greater of actual damages or $1000, plus punitive damages, court costs,
attorney’s fees and up to two years imprisonment.
VOLUNTEER RELEASE ORDER FORM
Company YMCA of
Metropolitan Denver
Office
Manager Contact____
____
_________
Phone
________________________________
Email address: ______________________________
In
connection with my volunteer application, I understand that investigative
background inquiries are to be made on me including criminal convictions and
motor vehicle reports. These
reports may include information as to my character, work habits, performance,
education, workers compensation claims and experience along with reasons for
termination of employment from previous employers. Further, I understand that you will be
requesting information from various Federal, State, and other
agencies.
I
authorize without reservation, any party or agency contacted to furnish the
above mentioned information and release all parties involved from any liability
and responsibility for doing so. I
hereby consent to the YMCA of Metropolitan Denver obtaining the above
information from Employment Screening Alliance Group. This authorization and consent shall be
valid in original, fax or copy form.
I
have the right to make a request of Employment Screening Alliance Group, upon
proper identification and the payment of any authorized fees, for the
information in its files on me at the time of my request. I further authorize ongoing procurement
of the above mentioned reports at any time during my volunteering for the YMCA
of Metropolitan Denver.
Volunteer Applicant’s
Signature
Date
PLEASE PRINT
CLEARLY
First Name __ ________
Middle Name
Last Name_______________________
SSN
Gender
Birth Date
Race_________________
Drivers License Number
State
Addresses for past
5-years:
Current Address
City
State
Zip
County
Years
there:
Previous Address
City
State
Zip
County
Years
there:
to
Previous Address
City
State
Zip
County
Years
there:
to
FOR YMCA USE
ONLY
In
accordance with the Fair Credit Reporting Act, you must:
§
Disclose to the applicant, in
a separate document, that a consumer report may be
obtained.
§
Obtain written consent before
ordering any reports.
§
Advise the applicant of
adverse information if used to deny employment, provide applicant with report
and give them consumer rights.
______ Social Security
Report: _____
______ Out of State
MVR:
Department Volunteer is
working in________________________________ GL account to
charge__________________________
06/01/04
branch – department – pcs