Background Check Form

Ronald McDonald House Charities of Nashville Guest Applicant Background Check Authorization:

As part of the Guest Application process for Ronald McDonald House Charities of Nashville (RMHC), I understand that RMHC may hire Selection.com to obtain “Consumer Reports” about me as defined in the Fair Credit Reporting Act (FCRA). These “Consumer Reports” may include all of my criminal his-tory. I understand that RMHC may rely on any or all of the above-referenced information to determine my eligibility for temporary residency. If RMHC considers making an adverse, residency-related decision that will affect me based, in whole or in part, upon a “Consumer Report” obtained from Selection.com, I will be offered a copy of the “Consumer Report” and a written summary of my “Consumer Rights” under the FCRA before RMHC finalizes that decision. I have read the above disclosure and I hereby authorize Ronald McDonald House Charities of Nashville, TN, Inc., and Selection.com or its authorized agents to obtain the above-referenced information about me. I also authorize all agencies, bureaus, employers, information service organizations and individu-als to provide any of the above-referenced knowledge or information they have concerning me. Fur-thermore, this authorization shall remain on file and shall serve as an ongoing authorization for RMHC to obtain “Consumer Reports” about me from SMS at any time during my temporary residency at RMHC. A photocopy or facsimile of this authorization shall be as valid as the original.

***PLEASE READ THE PARAGRAPH ABOVE AND ENTER YOUR NAME BELOW. BY ENTERING MY NAME BELOW, I UNDERSTAND THAT I AM SUBMITTING MY SIGNATURE ELECTRONICALLY*

First Last

THE FOLLOWING INFORMATION IS REQUIRED TO CONDUCT THE BACKGROUND INVESTIGATION

PATIENT'S NAME*

First Last

Name*

Last First Middle Initial

Previous Name (if applicable)

First Last

Phone*

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Social Security Number*

Driver's License Number*

State Issued*

Notice to Applicants Living in CA, OK, or MN

Email address

By entering my email address, I authorize Selection.com to deliver my Report via email.

By checking this box, I request to receive a free copy of any Report ordered on me.

Notice to California Residents: Notice to California Residents: Under section 1786.22 of the California Civil Code, you may view the file maintained on you by Selection.com during normal business hours. You may also obtain a copy of this file, either in person or by mail, by submitting proper identification and paying the costs of duplication services. You may also receive a summary of the file by telephone by being able to provide adequate identification as to allow Selection.com to determine with reasonable certainty that you are the subject of the report. Selection.com is required to have personnel available to explain your file to you and must explain to you any coded information appearing in your file. If you appear in person, another person of your choice may accompany you, providing that this additional person furnishes proper identification.

Ronald McDonald House Charities of Nashville Guest Applicant Background Check Authorization:

**THE FOLLOWING INFORMATION IS REQUIRED TO CONDUCT THE BACKGROUND INVESTIGATION**

***Notice to Applicants Living in CA, OK, or MN***

THE FOLLOWING INFORMATION IS REQUIRED TO CONDUCT THE BACKGROUND INVESTIGATION

Notice to Applicants Living in CA, OK, or MN