[ + ]   Federal Disclosure

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT

Checkmark you have read and understand both the FCRA Disclosure Statement and FCRA Summary of Rights (REQUIRED):

[ + ]   State, Local and Other Disclosures
Some states and localities provide additional rights, in addition to the federal rights described above. As a courtesy to you, Cluso Investigation provides certain information about these laws. If you live in any of the following states or cities -- or if you would move to any of the following states or cities if you are hired – click below for further information. (Note: While Cluso Investigation endeavors to provide complete and up-to-date information, it makes no guarantee that this information about state and local laws is complete or current.)












I acknowledge that I have read and understand the above applicable state/local disclosures or, if none provided, that the above locations are not applicable to me (REQUIRED):

 (REQUIRED):

[ + ]   Instructions
[ + ]   Personal Information
Enter your legal name as it appears on your Government-Issued ID, Passport or Driver's License
Legal First Name:
Legal Middle Name:
Legal Last Name:
Suffix (ex: Jr., Sr., if applicable):
Gender:
Your Email Address:
Your Telephone Number:
If applicable, list your Maiden name:
Have you ever used another name (Y/N):
If you marked Yes to "Alias", list the names in the following fields:
SSN (US only):
Canada SIN:
Date of Birth (format MM/DD/YYYY):
Drivers License Country:

Drivers License State/Province:

Drivers License #:

UAN (Universal Account Number):
Note: UAN is for India only. If you were provided a UAN then enter it. If multiple UANs have been issued, then separate with a comma.

[ + ]   Fill this Section if you Lived or Worked outside of the USA in the past @ERROR years
Nationality (if Non-USA):

Passport Issuing Country (if Non-USA):

Passport Number (if Non-USA):
PAN or Other National Citizen ID (non-USA):
If you hold a non-USA issued Passport, list your father's name:
If you hold a South American Passport, list your Mother's maiden name:

Passport/ID Scan:


[ + ]   Residential Address History

List Your Current Address:


Country:

Street: Apt Num/Suite/Other:
City: State/Province:

Zip/Postal Code:
Date Range (format MM/YYYY): to Present

List All Previous Addresses Lived Within the Past Years:


[ + ]   Employment History

List all Employers In the Past 7 Years:


* Consent is required to process your background check. By submitting this form, you are providing consent to contact all employers. Your current employer will only be contacted if you are hired and after your first day of employment. If you decline to provide consent to contact an employer, contact your recruiter before submitting this form.
1. Employer Name (The Company Providing a PAYSTUB OR W2):
  • If you worked directly as an employee (on W-2 or similar), independent contractor (on 1099 or similar), volunteer, or intern (paid or unpaid) of a company, then enter that company's name.
  • If the company name on your paystub or W-2 is only the payroll provider (e.g. Justworks or TriNet), then list the actual company's name that you worked for.
  • If you worked through a consulting or temp agency and that agency paid you, then list the consulting / temp company. Do not list the end client project company.
  • If you own(ed) a business and worked on contract with another company Corp-to-Corp (C2C), then list your company and not your client or the company that you invoiced.
Employment Type:

Country:

Street: Suite No:
City: State/Province:
Zip/Postal Code:
Area Code /Tel Number:
Start Date (format MM/DD/YYYY):
End Date (format MM/DD/YYYY):
Position/Title:
List Registration or Assigned Employee ID, Website or other company contact details for verification:
If Int'l, ATTACH Proof and/or Relieving Letter Here:

[ + ]   ADD UNEMPLOYED TIMEFRAME-GAP
Gap Start Date (format MM/DD/YYYY):
Gap End Date (format MM/DD/YYYY):
Activities During Gap Period:
Address of stay during the gap:
Were you involved in any criminal cases or in jail during the gap period (Yes/No)?:
Person who can confirm activities during Gap Period:
Provide an email address for this person:
Provide telephone number for this person:
Provide contact's relationship to yourself (e.g. co-worker, friend):
* Consent is required to process your background check. By submitting this form, you are providing consent to contact all employers. Your current employer will only be contacted if you are hired and after your first day of employment. If you decline to provide consent to contact an employer, contact your recruiter before submitting this form.
2. Employer Name (The Company Providing a PAYSTUB OR W2):
  • If you worked directly as an employee (on W-2 or similar), independent contractor (on 1099 or similar), volunteer, or intern (paid or unpaid) of a company, then enter that company's name.
  • If the company name on your paystub or W-2 is only the payroll provider (e.g. Justworks or TriNet), then list the actual company's name that you worked for.
  • If you worked through a consulting or temp agency and that agency paid you, then list the consulting / temp company. Do not list the end client project company.
  • If you own(ed) a business and worked on contract with another company Corp-to-Corp (C2C), then list your company and not your client or the company that you invoiced.
Employment Type:

Country:

Street: Suite No:
City: State/Province:
Zip/Postal Code:
Area Code /Tel Number:
Start Date (format MM/DD/YYYY):
End Date (format MM/DD/YYYY):
Position/Title:
List Registration or Assigned Employee ID, Website or other company contact details for verification:
If Int'l, ATTACH Proof and/or Relieving Letter Here:

[ + ]   Education History

List Highest Degree Received


Note: If you did not graduate or receive a degree or diploma then select "None". Only enter claims which you have completed. School/Degree Type:


[ + ]   ADD ANOTHER SCHOOL
Note: If you did not graduate or receive a degree or diploma then select "None". Only enter claims which you have completed. School/Degree Type:
[ + ]   Gap Reference
GAP ANALYSIS CONTACT
Provide a person who can verify your activities during any Gaps we find after verifying Employment and Education dates:
Provide an email address for this person:
Provide telephone number for this person:
Provide contact's relationship to yourself (e.g. co-worker, friend):
[ + ]   References

Please provide professional reference(s)

  • All references will be contacted as part of this background check, and consent to do so is required.
1. Reference Name:
Reference Type:
List His/Her Relationship to You:
Years Known?
Telephone Number:
Email:
2. Reference Name:
Reference Type:
List His/Her Relationship to You:
Years Known?
Telephone Number:
Email:
[ + ]   Professional Licenses/Certifications
1. License/Certification Name:
Institution Issuing the License/Certification:
Website for Institution:
License/Certification Number:
License/Certification Issuance Date:
License/Certification Expiration Date:
2. License/Certification Name:
Institution Issuing the License/Certification:
Website for Institution:
License/Certification Number:
License/Certification Issuance Date:
License/Certification Expiration Date:
[ + ]   Payment
Credit Card Type:
Credit Card Number:
Expiration Date:
Security Code:

Name on the Card:

Country:

Street: Apt Num/Suite/Other:
City: State/Province:

Zip/Postal Code:


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

[ + ]   Authorization, Release, and Arbitration Agreement

ANY DISPUTE BETWEEN YOU (THE CANDIDATE FOR EMPLOYMENT) AND CLUSO INVESTIGATION OR ANY OF ITS OFFICERS, EMPLOYEES, AGENTS, OR REPRESENTATIVES WHICH CANNOT BE RESOLVED AMICABLY WILL BE RESOLVED BY BINDING ARBITRATION IN DALLAS COUNTY OR TARRANT COUNTY, TEXAS AND NO OTHER LOCATION, UNDER TEXAS AND U.S. LAW, UNDER THE COMMERCIAL ARBITRATION RULES OF THE AMERICAN ARBITRATION ASSOCIATION, AND JUDGMENT MAY BE ENTERED UPON THE AWARD IN ANY COURT OF COMPETENT JURISDICTION. YOU AND CLUSO INVESTIGATION AGREE AND WARRANT THAT EACH OF US MAY BRING CLAIMS AGAINST THE OTHER ONLY ON AN INDIVIDUAL BASIS AND NOT ON A CLASS, REPRESENTATIVE, OR COLLECTIVE BASIS, AND YOU AND CLUSO INVESTIGATION HEREBY WAIVE ALL RIGHTS TO HAVE ANY DISPUTE BE BROUGHT, HEARD, ADMINISTERED, RESOLVED, OR ARBITRATED ON A CLASS, REPRESENTATIVE, COLLECTIVE BASIS OR TO HAVE ANY DISPUTE HEARD BY JURY TRIAL. ONLY INDIVIDUAL RELIEF IS AVAILABLE, AND DISPUTES OF MORE THAN ONE PERSON CANNOT BE ARBITRATED OR CONSOLIDATED WITH THOSE OF ANY OTHER. THE ARBITRATOR MAY AWARD RELIEF ONLY IN FAVOR OF THE INDIVIDUAL PARTY SEEKING RELIEF AND ONLY TO THE EXTENT WARRANTED BY THE PARTY’S INDIVIDUAL CLAIM. If a court decides by means of a final decision, not subject to any further appeal or recourse, that the limitations of this section are invalid or unenforceable as to a particular claim or relief, you and Cluso Investigation agree that that particular claim or relief shall be severed from the arbitration and shall be litigated in the state or federal courts in and for Dallas County or Tarrant County, Texas and no other location. This subsection does not prevent you or Cluso Investigation from participating in a class-wide settlement of claims.

Your Text Signature:

Draw your signature by holding the left mouse button and dragging or by using your touchscreen.
Clear

and Print Name:

Signature Date (format MM/DD/YYYY):

Print

NOTE: If you get an error message after submission, hit the back button, correct and submit again.
The most likely cause of errors are file attachments. Try reducing the size of each attachment to under 1MB.
There is a 10 MB maximum limit for all documents combined using this form. Exceeding this limit will result in unsuccessful submission. Any additional documents / information not attached to this form can be uploaded to https://secure.cluso.com/DocUpload
The 10 MB limit exists on that page also but can be submitted multiple times if necessary.
If you are unable to submit the form for any other reason you can always print and email this authorization form with your attachments to ops@cluso.com with subject "Online Authorization Form with Attachments." Email size is limited to 4 MB so anything above will need to be submitted using the DocUpload link.
Be sure to include your name and the company you are filling the authorization form for.
If you are still experiencing issues, make note of the error message and contact us at ops@cluso.com with subject "Online Authorization Form Error."