Background Check Authorization Form Template
A free background check authorization form built around the federal standalone disclosure requirement: a clear-and-conspicuous disclosure document, a separate written authorization, and the applicant identifiers a screening company needs. Download in PDF or Word.
Last updated: August 5, 2026
What Is a Background Check Authorization Form?
A background check authorization form is the document an employer uses to obtain an applicant's written permission before ordering a consumer report from a third-party screening company. Under the federal Fair Credit Reporting Act, an employer that uses a consumer reporting agency to check criminal records, employment history, education, motor vehicle records, or credit must first give the applicant a clear and conspicuous written disclosure in a document that consists solely of that disclosure, and must obtain written authorization.
The word "solely" is the part that generates litigation. Courts have repeatedly found employers in violation for burying the disclosure inside a job application, combining it with a liability release, or adding state-law notices and extraneous text to the same page. The safe structure is a standalone disclosure page, an authorization that may appear on the same page as the disclosure or on its own page depending on your counsel's guidance, and any state-specific notices delivered separately. If the employer later takes adverse action based on the report, a separate pre-adverse and adverse action process applies, with a copy of the report and a summary of rights provided before the decision becomes final.
When to Use This Template
- ✓You use a third-party screening company to run criminal, employment, education, or credit checks on applicants
- ✓A conditional offer has been extended and the background check is the remaining contingency
- ✓You screen current employees for promotion, transfer, or a role with new access or licensing requirements
- ✓Your role requires driving and you need authorization to pull a motor vehicle record
- ✓You are replacing an old combined application-and-consent form that mixes the disclosure with other text
- ✓You want a documented, dated consent record for every candidate screened
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Full text of the template. Fields in [BRACKETS] are placeholders you fill in.
Background Check Authorization Form
1. 1. Standalone Disclosure Regarding Consumer Reports
IMPORTANT — PLEASE READ CAREFULLY. This page is a disclosure and contains no other information. [COMPANY NAME] ("the Company") may obtain one or more consumer reports or investigative consumer reports about you from a consumer reporting agency for employment purposes, including for the purposes of evaluating you for employment, promotion, reassignment, retention, or continued employment. These reports may be obtained at any time after receipt of your authorization and, where you have agreed to ongoing authorization, throughout your employment to the extent permitted by law. A consumer report may contain information about your character, general reputation, personal characteristics, and mode of living, and may include information from public records and from interviews. This document must not be combined with a job application, a liability release, an arbitration provision, or any other content, and any state-specific notices are provided to you separately.
2. 2. Scope of the Report
The report may include, to the extent permitted by applicable federal, state, and local law, the following categories of information: criminal records, including county, statewide, federal, and national database searches; verification of prior employment, including dates, position, and reason for separation where lawfully obtainable; verification of education, degrees, certifications, and professional licenses; motor vehicle and driving records, where the position involves driving; sex offender registry searches; national and international sanctions and watch list searches; social security number trace and address history; and, only where permitted by law and relevant to the position, credit history. Not all categories will be requested for every position, and the specific searches ordered for this position are: [LIST SEARCHES ORDERED FOR THIS ROLE].
3. 3. Consumer Reporting Agency Information
The consumer reporting agency preparing the report is [SCREENING COMPANY NAME], located at [SCREENING COMPANY ADDRESS], telephone [SCREENING COMPANY PHONE], website [SCREENING COMPANY WEBSITE]. You may contact this agency directly to request information about the nature and scope of any investigative consumer report prepared about you and to request a copy of any report it has furnished about you. The agency has provided the Company with a copy of the federal summary of your rights under the Fair Credit Reporting Act, which is furnished to you together with this disclosure as a separate document.
4. 4. Applicant Identifying Information
Complete the following so that records can be accurately matched to you. Full legal name: [FULL LEGAL NAME]. Other names used, including maiden or former names: [OTHER NAMES AND DATE RANGES]. Date of birth: [DATE OF BIRTH — collected solely to identify records accurately and not used in any hiring decision]. Social security number: [SOCIAL SECURITY NUMBER]. Driver license number and issuing state: [LICENSE NUMBER AND STATE], required only where the position involves driving. Current address: [STREET, CITY, STATE, ZIP], since [MOVE-IN DATE]. Prior addresses for the past [NUMBER] years: [PRIOR ADDRESSES WITH DATE RANGES]. Telephone: [PHONE NUMBER]. Email: [EMAIL ADDRESS]. Position applied for: [POSITION TITLE].
5. 5. Authorization and Consent
I have read and understand the disclosure provided to me, and I authorize [COMPANY NAME] to obtain consumer reports and investigative consumer reports about me from [SCREENING COMPANY NAME] or another consumer reporting agency for employment purposes. I authorize any person, business, educational institution, law enforcement agency, government agency, or former employer having information about me to release that information to the consumer reporting agency or to the Company, to the extent permitted by law. I understand that I may withdraw this authorization at any time by written notice to the Company, and that withdrawal will not affect reports already obtained. I understand that providing this authorization is voluntary, and that a decision not to provide it may mean the Company cannot proceed with my application for a position that requires screening.
6. 6. Ongoing Authorization (Optional — Initial to Accept)
This section is optional and applies only if you initial below. Where permitted by applicable state and local law, I authorize the Company to obtain consumer reports about me at any time during my employment, without providing a new disclosure and obtaining a new authorization for each report. I understand that some states do not permit an evergreen authorization of this kind and that in those states a new disclosure and authorization will be provided before each report. I understand that I may revoke this ongoing authorization at any time by written notice to [HR CONTACT NAME] at [HR CONTACT EMAIL]. Applicant initials to accept ongoing authorization: ________. Applicant declines ongoing authorization: ________.
7. 7. Summary of Rights and Adverse Action Process
You are being provided with a copy of the federal document titled "A Summary of Your Rights Under the Fair Credit Reporting Act" as a separate attachment, together with any state-required notice applicable to your location. If the Company considers taking adverse action against you based in whole or in part on information in a consumer report, you will first receive a pre-adverse action notice, a copy of the report, and a copy of the summary of rights, and you will be given a reasonable period of time to review the report and dispute inaccurate or incomplete information with the consumer reporting agency before a final decision is made. If the Company then takes adverse action, you will receive a written adverse action notice identifying the consumer reporting agency and explaining your rights, including your right to obtain a free copy of the report from the agency within the statutory period and your right to dispute its accuracy.
8. 8. State-Specific Notices
Certain states and localities require additional notices or provide additional rights, and those notices are provided to you as a separate attachment rather than being combined with the disclosure in Section 1. Applicable jurisdiction for this application: [STATE AND, IF APPLICABLE, CITY OR COUNTY]. Additional notices provided: [LIST ATTACHED STATE OR LOCAL NOTICES]. If you would like a free copy of any report obtained about you, indicate your request here: [ ] Yes, please provide me with a copy of the report. Deliver the copy to: [EMAIL OR MAILING ADDRESS FOR THE COPY]. Some jurisdictions also restrict when criminal history may be considered, limit consideration of certain records, and require an individualized assessment before adverse action; the Company will follow those requirements where they apply.
9. 9. Applicant Signature
By signing below I confirm that I have received and read the disclosure, that the identifying information I provided is accurate and complete, and that I authorize the background check described above. I understand that an electronic signature has the same effect as a handwritten signature. Applicant signature: ______________________. Printed name: [FULL LEGAL NAME]. Date: [DATE]. For company use only — Received by: [HR REPRESENTATIVE NAME]. Date received: [DATE]. Disclosure provided as a standalone document: [YES]. Summary of rights provided: [YES]. State notices provided: [YES / NOT APPLICABLE]. Report ordered on: [DATE ORDERED]. Retention: this form is retained separately from the personnel file for [RETENTION PERIOD] in accordance with company policy.
10. Disclaimer
This template is provided for general informational purposes only and is not legal advice. Background screening is governed by the federal Fair Credit Reporting Act and by a dense and frequently changing layer of state and local law, including ban-the-box and fair chance ordinances, restrictions on the use of criminal and credit history, limits on evergreen authorizations, and specific notice and individualized assessment requirements. Claims for defective disclosure forms are a very active area of class action litigation, and the technical requirements are unforgiving. Do not adopt this form without review by employment counsel licensed in each jurisdiction where you hire, and coordinate the form with your screening vendor. Use of this template does not create an attorney-client relationship with ScanContract.
Key Clauses Explained
What each important clause does — and what to watch out for before you sign.
Standalone Disclosure
Provides the clear and conspicuous written disclosure in a document that contains nothing else, as federal law requires.
This is where most employers get sued. Do not staple the disclosure to the application, add a liability release, include an arbitration clause, or pile state notices onto the same page. Applicants who see the disclosure buried inside an application are looking at a form that likely does not comply.
Written Authorization
Captures the applicant's signed permission to obtain the consumer report.
The authorization must be genuine consent, not a checkbox buried in an onboarding portal with no chance to read the disclosure first. Applicants should understand that declining generally ends consideration for roles that require screening, so ask questions before signing rather than after.
Scope of the Report
Lists what categories of information may be obtained and which searches are actually ordered for the role.
Order only what the role justifies. Credit checks in particular are restricted in several states and are hard to defend for positions with no financial responsibility. Applicants should note which searches are listed and ask why any category unrelated to the job is included.
Applicant Identifying Information
Collects the identifiers a screening company needs to match records to the right person.
Date of birth and social security number are collected for identity matching only and must never influence the hiring decision; keep this form out of the general personnel file and restrict access. Applicants should provide accurate former names and addresses, since gaps are the leading cause of mismatched records.
Ongoing (Evergreen) Authorization
Optionally permits repeat checks during employment without a fresh disclosure each time.
Several states do not honor evergreen authorizations, so a single national form that assumes they are valid creates exposure. Make it a separate, initialed, genuinely optional election. Employees should understand that initialing here permits periodic re-screening for as long as they work there.
Adverse Action Process
Explains the pre-adverse and adverse action steps that must occur before and after a decision based on the report.
The pre-adverse notice with a copy of the report and a real waiting period is mandatory, not a courtesy, and skipping it is a common and expensive mistake. Applicants should use that window to dispute inaccurate records with the agency, since screening reports frequently contain mismatches.
State and Local Notices
Delivers jurisdiction-specific notices separately so they do not contaminate the standalone disclosure.
Ban-the-box and fair chance rules also control when in the process you may ask about or consider criminal history, and several require an individualized assessment before rejecting a candidate. A national form that ignores the applicant's city or county is a compliance gap, not a shortcut.
Frequently Asked Questions
What is the FCRA standalone disclosure requirement?▾
Can the disclosure and the authorization be on the same page?▾
What must happen before we reject someone based on the report?▾
Do we need a new authorization for each background check?▾
When can we ask about criminal history?▾
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