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Extended Background Check (EBC) Authorization Form
CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK IN COMPLIANCE WITH THE
FCRA (FAIR CREDIT REPORTING ACT)
Date:_____________
______________________
Last Name
______________________
First Name
_______________________
Middle Name
__________________________________
Maiden and/or Other Last Names Used
____________________________________________________ ________________________
Address* Phone Number
____________________
City*
_______________ ________
State* Zip Code
(1) _____________ (2) ______________
List last two Counties that you lived in *
______________________
Date of Birth
______________________
Social Security Number
Circle
One:
Male
Female
This authorization and consent for release of personal information acknowledges that Oklahoma Board of Social Work
Licensure (Hereafter referred to as "Company") and/or its agent, Trak-1 Technology, may now conduct investigations
whether the records are of a public, private or confidential nature. These investigations might include, but are not limited
to, financial statements; records of previous employment, including work history, records and recollections of attorney-
at-law or of other counsel, whether representing me or any other person (in either a civil or criminal case in which I have
been involved); criminal history information of file in local, state or federal agencies; and motor vehicle records, and
following an offer, workers' compensation reports from either the Department of Labor, National Personnel Records or the
Industrial Commission or similar agencies under the provisions of the Fair Credit Reporting Act 15, USC section 1681 et
seq. I also authorize the National Personnel Records Center, or other custodian of my military service record, to release
to Trak-1 Technology, the following information and/or copies of documents from my military service record: DD214,
service record, and any disciplinary records.
I understand that these searches will be used to determine eligibility under the Company's policies. Therefore, I authorize
and consent for full release of records (either orally or in writing) to the authorized representatives of the Company. In
addition, I release and discharge the Company and its agent and associates to the full extent permitted by law from any
claims, damages, losses, liabilities, costs expenses or any other charge or complaint filed with any agency arising from
retrieving and reporting this information. I understand that according to the Federal Fair Credit Reporting Act, I am
entitled to know whether licensing was denied based upon the information obtained and to receive, upon written request,
a disclosure of the background report. I also understand that I may request a copy of the report from Trak-1
Technology / PO Box 130159 Houston, Texas 77219 at telephone number 1-800-600-8999. After reading this
document, I fully understand its contents and authorize the background verification.
Are you applying for employment in California, Minnesota or Oklahoma? Yes ___ No___
If so, do you want a copy of any Consumer Report prepared concerning you? Yes ___ No ___
I understand that California law required Company to give me a copy of any report requested within seven (7) days of
the date the information was obtained and that failure to do so will expose Company to liability (Section 1786.29).
* AS SHOWN ON THE ORIGINAL APPLICATION
Full Disclosure
If you have legal (civil or criminal) issues from your past, they should be disclosed. DO NOT rely on your past legal issues being
expunged, even if you were told that by the court, lawyers or other persons. It is our experience that records thought to have been
expunged or undiscoverable will eventually show up. It is better for you to tell the Board about the infraction(s) than to have
them discovered later and it “appear” as an intentional misrepresentation. The information received from this Extended
Background Check will be compared to information supplied with your application for accuracy.
The following are my responses to questions about my criminal record history (if any) with descriptions to any question with a