Cluso Investigation
4500 Mercantile Plaza Dr Suite 106
Fort Worth, TX 76137
Tel: (866) 685-5177 Fax: (817) 945-2297
Backup Fax Number: 1-(214) 853-4423
TX PI Lic: A16821
Email: sales@cluso.com Website: www.cluso.com


Policy/Position Code: egoCertified

Background Check Release Form

Section 1. Instructions Please complete the Background Check Release Form by providing all information requested.
Please fill in this form, read the Fair Credit Reporting Rights information
and Press the SUBMIT button.


Any documents, proof, or other information you are submitting can be attached to this form in the appropriate section. Please ONLY Attach PDF files or small sized (under 1 MB) non-PDF files.

Section 2. Applicant Information
INDIVIDUAL TO BE INVESTIGATED:


Username: - REQUIRED
Password: - REQUIRED
Legal Last Name: - REQUIRED
Legal First Name: - REQUIRED
Legal Middle Name:
Suffix (ex: Jr., Sr., if applicable):
Gender (M/F):
Your Email Address: - REQUIRED
Your Tel: Number: - REQUIRED
If applicable, Please list your Maiden name:
Have you have used another name (Y/N):
If you marked Yes to "Alias", Please list the names in the following fields:1.
2.
3.
4.
SSN (format XXX-XX-XXXX) - REQUIRED
DOB (format MM/DD/YYYY) - REQUIRED

List Your Current Address (REQUIRED):
1. Street:
Apt Num/Suite/Other:
City: State:
Zip: Country:
Date Range (format MM/YYYY): to

Section 3. Employment History Information



- Include only direct employers (the employer name on your paycheck) and not end-client project company names)
- If you are submitting a closed company, please attach paystub proof or email sales@cluso.com
- If you are claiming non-USA Employment, please attach provide proof documents or email sales@cluso.com

1. Employer Name:
Area Code /Tel Number:
Street: Suite No:
City: State:
Postal Code: County:
Country:
Start Date (format MM/DD/YYYY): End Date (format MM/DD/YYYY):
Position/Title:
Do we have permission to contact (Y/N)?
If India or International Employment, Please list Registration or Assigned Employee, Website
or other company contact details for verification:

If Int'l Employment, ATTACH Proof and/or Relieving Letter Here:

2. Employer Name:
Area Code /Tel Number:
Street: Suite No:
City: State:
Postal Code: County:
Country:
Start Date (format MM/DD/YYYY): End Date (format MM/DD/YYYY):
Position/Title:
Do we have permission to contact (Y/N)?
If India or International Employment, Please list Registration or Assigned Employee, Website
or other company contact details for verification:

If Int'l, ATTACH Proof and/or Relieving Letter Here:

3. Employer Name:
Area Code /Tel Number:
Street: Suite No:
City: State:
Postal Code: County:
Country:
Start Date (format MM/DD/YYYY): End Date (format MM/DD/YYYY):
Position/Title:
Do we have permission to contact (Y/N)?
If India or International Employment, Please list Registration or Assigned Employee, Website
or other company contact details for verification:

If Int'l, ATTACH Proof and/or Relieving Letter Here:

Section 4. Highest Degree/Diploma Obtained.

Highest Degree Received:
University/School: (Fully List Name unabbreviated):
Area Code /Tel Number:
Street:
Suite/Apt:
City: State:
Postal Code: Country:

SKIP This Grey Section if USA School. Fill Grey if Non-USA School:
College Name (Fully List Name not abbreviated):
Area Code /Tel Number:
Street:
Suite/Apt:
City: State:
Postal Code: Country:

Start Date (format MM/YYYY): End Date (format MM/YYYY):
Graduate? (Y/N):
If Yes,Grad Date (format MM/YYYY):
List Degree Received:
List Major:
Name you had while attending school:
If non-USA, provide Roll/Registration/Student Number:
If India or non-USA Country list Website or
other helpful contact information:

If Int'l, ATTACH Degree and/or Marksheet Here:
If Int'l, ATTACH Degree and/or Marksheet Here:


Section 5. Professional References

1. Reference Name:
Area Code /Tel Number:
Email (if available):
Years Known?
List if Supervisor, Peer, or Subordinate:
2. Reference Name:
Area Code /Tel Number:
Email (if available):
Years Known?
List if Supervisor, Peer, or Subordinate:


Section 6. Professional Licenses/Certifications

1. License Name:
Institution Issuing the License:
Website for Institution:
License Number:
License Issuance Date:
License Expiration Date:
2. License Name:
Institution Issuing the License:
Website for Institution:
License Number:
License Issuance Date:
License Expiration Date:
3. License Name:
Institution Issuing the License:
Website for Institution:
License Number:
License Issuance Date:
License Expiration Date:

Section 7. Background Check Payment Information

Credit Card Type:
Credit Card Number:
Expiration Date:
Security Code:

Name on the Card:
Billing Address:

Street:
Apt Num/Suite/Other:
City: State:
Zip: Country:

Section 8. Authorization for Background Check Payment
Invoices will be sent for your review to the email address indicated above. Your card will not be automatically charged.

Please be aware that your credit card and invoice will not exceed $169.00. However, the charge may be less with a less complicated background check. You will receive a credit authorization receipt via email after your credit card is charged. If you have any questions please email accounting@cluso.com.

Cluso Investigation is in compliance with the PCI DSS (Payment Card Industry Data Security Standard.)

To pay with your credit card on file, email accounting@cluso.com the total amount and invoice(s) you would like to authorize for payment.

To change or remove card information, email sales@cluso.com. If you have any questions, please call 817-945-2289 ext 0.

I authorize Cluso Investigation to charge the credit card indicated in this web form in accordance to the above terms. This payment is for a consumer background check report on myself. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company, so long as the transaction corresponds to the terms indicated in this web form.

Thanks for your business!

Checkmark you understand and agree the above stated terms for payment of this background check: - REQUIRED

Section 9. Authorization for Investigation and Information Release

In consideration of being considered by Cluso Investigation or its customer for a position, I hereby authorize Cluso Investigation and its agents, including but not limited to Cluso Investigation, to perform the required investigative inquiries into my personal background, covering the counties, states, or federal districts where I have been employed or resided for 7 years. Cluso Investigation and its agents, including but not limited to Cluso Investigation, have my authorization to develop information regarding my work habits, skills, and general character from employers, personal references, schools, or institutions, including but not limited to state workers’ compensation histories, and/or obtain information from law enforcement, judicial, and military authorities concerning my conduct or criminal history (including but not limited to traffic violations), and to share such information with Cluso Investigation’s customer if applicable.

I authorize any current or former employer, school, or other organization or entity identified herein to release any information about me to Cluso Investigation or Cluso Investigation, including but not limited to personnel records and any records concerning drug or alcohol testing or any refusal to consent to testing. A facsimile, photocopy or other copy of this authorization shall be deemed to be an original.



I understand that this Background Check Release Form is not to be deemed a request to obtain or release any information where such request or release is not permitted by applicable law. I further understand that the results of any pre-employment investigation, if found to be unsatisfactory according to the policy(ies) of Cluso Investigation or other applicable prospective employer, may be cause for denial of employment. I understand by providing my personal identifiers and typing electronically my name once for Printed Name and again for Signature, I am confirming authorization for Investigation without a separate handwritten signature. My electronic signature shall be deemed to be my original signature. This agreement may be executed in multiple counterparts, each of which shall be deemed an original for all purposes.

I hereby certify that all information furnished by me herein is true, complete, and accurate to the best of my knowledge. I hereby release Cluso Investigation, their respective affiliates and customers, and all officers, directors, agents, employees, and representatives of any of the foregoing, of and from any claims or liabilities of any kind resulting from such background investigations or the provision or use of information derived through such investigations, including but not limited to the denial of employment.



Please read your FCRA Rights Information below before electronically signing this release and pressing the Submit button. Any questions should be directed to "sales@cluso.com" with "Online Release Question" in the Subject line.

Checkmark you understand your FCRA Rights: - REQUIRED
For California, Oklahoma, or Minnesota residents, Checkmark here if you want
a copy of your final background check report:

For California, Oklahoma, or Minnesota residents, If you Checkmarked to receive a copy,
List your email address if you prefer to receive your copy via email
(otherwise you will receive by regular mail):

Applicant Text Signature: - REQUIRED
and Print Name: - REQUIRED
Date (format MM/DD/YYYY): - REQUIRED

Press Here To Submit Your Release Form. If you get an error message, please use go to "previous page", correct and press the submit button again





Cluso Investigation
4500 Mercantile Plaza Dr Suite 106
Fort Worth, TX 76137
Tel: (866) 685-5177 Fax: (817) 945-2297
Backup Fax Number: 1-(214) 853-4423
TX PI Lic: A16821
Email: sales@cluso.com Website: www.cluso.com


A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT

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 www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, DC 20580.

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 identify 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, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.ftc.gov/credit 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 www.ftc.gov/credit 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 www.ftc.gov/credit

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 1-888-567-8688.

• 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 www.ftc.gov/credit

. 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. Federal enforcers are:
________________
Consumer reporting agencies, Consumer Response Center - creditors and others not listed CONTACT: Federal Trade Commisson: Consumer Response Center FCRA Washington, DC 20580, 1-877-382-4357
_______________________
National banks, federal the Currency branches/agencies of foreign banks (word "National" or initials "N.A" appear in or after bank's name) CONTACT: Office of the Comptroller of the Currency, Compliance Management Mail Stop 6-6, Washington DC 20219, 1-800-613-6743
_______________________
Federal Reserve System member banks (except national banks and federal branches/agencies of foreign banks) CONTACT: Federal Reserve Board Divison of Consumer & Community Affairs Washington DC 20551, 202-452-3693
________________________
Savings associations and federally chartered savings banks (word "Federal" or initials "F.S.B." appear in federal institution's name) CONTACT:
Office of Thrift Supervision Consumer Complaints, Washington, DC 20552,800-842-6929
_________________
Federal credit unions (words "Federal Credit Union" appear in institution's name) CONTACT: National Credit Union Administration 1775 Duke Street, Alexandria VA 22314, 703-519-4600
_________________
State-chartered banks that are not members of the Federal Reserve System CONTACT: Federal Deposit Insurance Corporation, Consumer Response Center, 2345 Grand Ave, Suite 100, Kansas City, MO 64108-2638, 1-877-275-3342
_________________
Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission CONTACT: Department of Transportation, Office of Financial Management Washington DC 20590 202-366-1306
_________________

Activities subject to the Packers and Stockyards Act of 1921 CONTACT: Department of Agriculture, Office of Deputy Administrator - GIPSA, Washington DC 20250, 202-720-7051