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EXHIBIT B
DISCLOSURE TO PROSPECTIVE EMPLOYEES, VOLUNTEERS, OR OTHER
REPRESENTATIVES OR AGENTS OF CONTRACTORS REGARDING PROCUREMENT
OF A CONSUMER REPORT
(including a criminal history report)
In connection with your status as a prospective employee, volunteer, or other representative or agent of the
Contractor, Contractor and the City of Fort Collins may procure a consumer report/criminal history on you as
part of the process of considering your candidacy for said status. The investigation conducted in conjunction
with the report may include an investigation of your personal employment/volunteer history, education,
financial, and credit records, public records concerning your driving record, civil and criminal court records,
county, state, and Federal tax liens, notices of default and bankruptcies, and other records as may be
appropriate. In the event that information from the report is utilized in whole or in part in making an adverse
decision with regard to your potential employment/volunteer/representative/agent status, before making the
adverse decision, the City and the Contractor will attempt to provide you and the Contractor with a copy of the
consumer report/criminal history and a description in writing of your rights under the Federal Fair Credit
Reporting Act. The Fair Credit Reporting Act gives you specific rights in dealing with consumer reporting
agencies. A copy of A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT is
attached to this document.
By your signature below, you hereby authorize us to obtain a consumer report and/or an investigative report
about you in order to consider your status as a prospective employee, volunteer, or other representative or
agent for the Contractor.
Applicant’s Name:
(Please Print) First Middle Last
Signature: Date of Birth:
Applicant’ Address:
City/State/Zip:
Driver’s License #: Social Security #:
Signature of Parent or Guardian:
(if Applicant is under the age of 18):
Other names used in the last seven (7) years:
Previous out-of-state address(es) in the past seven (7) years.
1.
Address City County State Zip
2.
Address City County State Zip
Please list any additional addresses on the back of this page.
Contractor’s Initials: Date: City Staff Initials: Date: