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Eaton Soccer Form - please read below and fill out.


Eaton Soccer (“the Company”) may obtain information about you from a third party consumer reporting agency for employment purposes.  This information may be obtained in the form of a “consumer report” and/or an “investigative consumer report” (commonly known as a “background report”).  These reports may contain information regarding your criminal history, social security verification, motor vehicle records (“driving records”), credit history*, verification of your education or employment history, drug screening or other background checks. This information may be obtained from private and public record sources, including, as appropriate: government agencies and courthouses and educational institutions. The reports may also include information about your character, general reputation, personal characteristics, mode of living, etc., which can involve personal interviews with individuals or companies that you have listed as a reference, former employer, etc. A more comprehensive background investigation may be required pursuant to state or federal law, contract agreement or for certain sensitive positions (such as those with significant financial responsibilities). (*Please note that credit history will only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying.)


You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you, disclosure of the nature and scope of any investigative consumer report and to request a copy of your report.  Please be advised that the nature and scope of any investigative consumer report obtained with regard to applicants for employment is an investigation conducted by Reference Services, Inc. (RSI).  RSI is located and can be contacted by mail at 101 Plaza East Blvd, Suite 300, Evansville, IN 47715, and RSI can be contacted by phone at (800)881-0754.  Information about RSI’s privacy policy is available at the following link: The scope of this notice and authorization is all-encompassing and allows the Company to obtain from any outside organization all manner of consumer reports throughout the course of your employment or your contract period to the extent permitted by law.





Signature:________________________________                                                 Date: ___________________                         


I acknowledge receipt of the separate document entitled “Disclosure Regarding Background Investigation” and “A Summary of Your Rights under the Fair Credit Reporting Act” and certify that I have read and understand both of those documents.  I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Company at any time after receipt of this authorization and throughout my employment, or status as an Advisor, if applicable.  To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all drug screening and background information requested by Reference Services, Inc. [101 Plaza East Blvd, Suite 300, Evansville, IN 47715, (800)881-0754,] and/or the Company itself.  I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.


New York applicants only: Upon request, you will be informed whether or not a consumer report was requested by the Company, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. You have the right to inspect and receive a copy of any investigative consumer report requested by the Company by contacting the consumer reporting agency identified above directly. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law

Washington State applicants only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

Minnesota and Oklahoma applicants only:

Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company. □

California applicants only:

Under California Civil Code section 1786.22, you are entitled to find out what is in the CRA’s file on you with proper identification, as follows:

• In person, by visual inspection of your file during normal business hours and on reasonable notice. You also may request a copy of the information in person. The CRA may not charge you more than the actual copying costs for providing you with a copy of your file.

• A summary of all information contained in the CRA file on you that is required to be provided by the California Civil Code will be provided to you via telephone, if you have made a written request, with proper identification, for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to you.

• By requesting a copy be sent to a specified addressee by certified mail. CRAs complying with requests for certified mailings shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the CRAs.

“Proper Identification” includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. Only if you cannot identify yourself with such information may the CRA require additional information concerning your employment and personal or family history in order to verify your identity. The CRA will provide trained personnel to explain any information furnished to you and will provide a written explanation of any coded information contained in files maintained on you. This written explanation will be provided whenever a file is provided to you for visual inspection. You may be accompanied by one other person of your choosing, who must furnish reasonable identification. A CRA may require you to furnish a written statement granting permission to the CRA to discuss your file in such person’s presence.

Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law. □




Last Name ______________________________________ First __________________________ Middle _____________


Other Names/Aliases Used____________________________________________________________________________


Social Security Number* _______________________________________ Date of Birth* _________________________


Driver’s License Number _________________________________________ State of Driver’s License _______________


Current Address – Address, City, State, Zip_______________________________________________________________


Previous Address – Address, City, State, Zip _____________________________________________________________


Previous Address – Address, City, State, Zip _____________________________________________________________


Phone Number _______________________________ Email Address _________________________________________


Permission to contact current employer for employment and reference verifications:  oYes oNo


Signature _______________________________________________________Date_______________________________

*This information will be used as identification for background screening purposes only and will not be used as hiring criteria.

Notice Regarding Credit Checks Per California Law


Pursuant to Section 1024.5 of the California Labor Code, the Company informs you that it may obtain a credit report about you from the above named entity, because you are seeking to work in the following position:

[_] An employee covered by the executive exemption set forth in subparagraph (1) of paragraph (A) of Section 1 of Wage Order 4 of the Industrial Welfare Commission;

[_] A position in the state Department of Justice;

[_] A sworn peace officer or other law enforcement;

[_] A position for which the information contained in the report is required by law to be disclosed or obtained;

[_] A position that involves regular access to specified personal information for any purpose other than the routine solicitation and processing of credit card applications in a retail establishment, such as bank or credit card account information, social security number, or date of birth;

[_] A position which the person can enter into financial transactions on behalf of the company;

[_] A position that involves access to confidential or proprietary information;

[_] A position that involves regular access to $10,000 or more of cash; or

[_] The Company will not obtain a consumer credit report on you.


Notice Regarding Credit Checks Per Vermont Law


Pursuant to Vermont Act No. 154 (S. 95), the Company informs you that it may obtain a credit report about you, for the following reason(s):


[_] The information is required by state or federal law or regulation;

[_] You seek to be/are employed in a position that involves access to “confidential financial information” (defined as “sensitive financial information of commercial value that a customer or client of the employer gives explicit authorization for the employer to obtain, process, and store and that the employer entrusts only to managers or employees as a necessary function of their job duties”);

[_] The Company is a financial institution as defined in 8 V.S.A. §11101(32) or a credit union as defined in 8 V.S.A. §30101(5);

[_] You seek to be/are employed in a position as a law enforcement officer, emergency medical personnel or firefighter as these terms are respectively defines in 20 V.S.A. §2358, 24 V.S.A. §2651(6) and 20 V.S.A. §3151(3)  

[_] You seek to be/are employed in a position that requires a financial fiduciary responsibility to the Company or a Company’s clients, including the authority to issue payments, collect debts, transfer money or enter into contracts;

[_] You seek to be/are employed in a position that involves access to the Company’s payroll information;

[_] The Company can demonstrate that credit information is a valid and reliable predictor of employee performance in the your specific position of employment;

[_] The Company will not obtain a consumer credit report on you.



Summary of your rights

Para información en español, visite o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

• You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.

• You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if: • a person has taken adverse action against you because of information in your credit report; • you are the victim of identity theft and place a fraud alert in your file; • your file contains inaccurate information as a result of fraud; • you are on public assistance; • you are unemployed but expect to apply for employment within 60 days.

In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See for additional information.

• You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

• You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See for an explanation of dispute procedures.

• Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed

or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

• Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

• Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need – usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

• You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to

• You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-5678688.

• You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

• Identity theft victims and active duty military personnel have additional rights. For more information, visit

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact:

TYPE OF BUSINESS: CONTACT: 1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates.

b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the CFPB:

a. Consumer Financial Protection Bureau 1700 G Street NW Washington, DC 20552

b. Federal Trade Commission: Consumer Response Center – FCRA Washington, DC 20580 (877) 382-4357

2. To the extent not included in item 1 above:

a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks

b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and Insured State Branches of Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act

c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations

d. Federal Credit Unions

a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050

b. Federal Reserve Consumer Help Center P.O. Box 1200 Minneapolis, MN 55480

c. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106

d. National Credit Union Administration Office of Consumer Protection (OCP) Division of Consumer Compliance and Outreach (DCCO) 1775 Duke Street Alexandria, VA 22314 3. Air carriers Asst. General Counsel for Aviation Enforcement & Proceedings Aviation Consumer Protection Division Department of Transportation 1200 New Jersey Avenue, SE Washington, DC 20590 4. Creditors Subject to Surface Transportation Board Office of Proceedings, Surface Transportation Board Department of Transportation 395 E Street S.W. Washington, DC 20423 5. Creditors Subject to Packers and Stockyards Act, 1921 Nearest Packers and Stockyards Administration area supervisor

6. Small Business Investment Companies Associate Deputy Administrator for Capital Access United States Small Business Administration 409 Third Street, SW, 8th Floor Washington, DC 20416 7. Brokers and Dealers Securities and Exchange Commission 100 F St NE Washington, DC 20549 8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090 9. Retailers, Finance Companies, and All Other Creditors Not Listed Above FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center – FCRA Washington, DC 20580 (877) 382-4357

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