Please Note: You may be required to fill out a physical copy of this form.

    In connection with your employment, application for employment or temporary agency/contractor assignment, Goodwill Industries, may, upon execution of this authorization, investigate the information contained in this form, your application (employees/applicants), and other relevant background information to determine whether you are a suitable candidate for employment, promotion, or position reassignment or contract. Therefore, Goodwill Industries will request your consumer report from a third party agency. The scope of the consumer report requested by Goodwill Industries may include information relating to employment history, criminal history, driving history, and Social Security verification. The purpose of the background investigation is to solely determine eligibility at Goodwill Industries.

    If you do not authorize Goodwill Industries to conduct your background investigation, you will not be considered for employment, promotion, reassignment or contract. Your application may be withdrawn, you may be removed from your position or your contract may be terminated, if applicable.

    You have the right, upon written request made within a reasonable time (not to exceed 30 days) after receipt of this notice, to obtain information from Goodwill Industries:

    • As to whether an investigative consumer report has been requested

    • If an investigative consumer report has been requested, written disclosure of that nature and scope of the investigation requested

    • The name and address of the outside agency to whom requests for any of these reports has been made

    If the consumer report, in whole or in part, supports making an adverse decision affecting your employment or contract, Goodwill Industries will provide to your, before making the adverse decision, a copy of the consumer report and a description in writing of your rights under the Fair Credit Reporting Act. If you are ineligible or your background is unacceptable to Goodwill Industries, Goodwill Industries may not hire you or may remove you from your position, assignment or terminate your contract. If this information is retained, it will be kept confidential and separate from your personnel file, if you are hired.

    Last Name

    First Name


    Date of Birth YYYY-MM-DD

    Social Security Number

    Street Address




    I confirm that the information entered above is accurate and has not been falsified.

    I agree to the terms above and give Goodwill of Tenneva Area, Inc. permission to conduct a background investigation.

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