Your employer or prospective employer has conducted a criminal history search,
which has revealed information that may be your record. It is mandatory and
important for you to fill out this form with the criminal record report in
front of you.
As the prospective employer or existing employers do not automatically exclude an applicant
or employee with a criminal record, the following questions must be answered for your
application to be considered or for you to be eligible for continued employment.
The Fair Credit Reporting Act requires that you verify the accuracy of this report
to protect your rights.
Important information follows and requires your immediate response for you
to be considered an active applicant for employment and that your record
as provided to you is accurate. There are several benefits for your
immediate response, which include: (1) You let the prospective employer
know you are a serious candidate wanting to go to work. (2) You are
able to provide positive information to the prospective employer that
should be considered when reviewing your background records. (3) You
are able to identify inaccurate and accurate records that will insure
only the right information is being considered by the prospective employer.
As you authorized a pre-employment background checks was made as part
of your application for employment. This is to inform you that information
in the report, if accurate, may prevent your being offered employment by
the prospective employer. A copy of this report and A Summary of Your
Rights were previously sent to you.
To help expedite or speed up the hiring process you have five days to
answer a few questions to help us evaluate your background information.
We want you to provide this information, as we do not automatically
discriminate against applicants with a past record. We take in
consideration your explanations, the dates, records, and other information
to make sure we have a consistent and fair employment process in our
hiring decisions.
Though SecurTest, Inc., or its affiliates, provided this report, they
do not make the hiring decision. It is your obligation to make sure this
information is accurate, includes your explanations, and positive information
as to why we should consider you for employment.
A description of your rights under the federal Fair Credit Reporting
Act was previously provided to you with a copy of the report. Under the
law, you may dispute, directly with SecurTest, Inc., any information in
this report. The form that follows helps you verify the accuracy of the
report. They will reinvestigate the disputed information free of charge
to you and either record the current status of the disputed information
or delete the item(s) within thirty days of receiving your dispute. If
the information is found to be inaccurate or incomplete or cannot be
verified, they will promptly delete that item or modify it. They will
provide notification of the dispute to any person who provided the
information you dispute within five business days of receiving your
notice of dispute. The enclosed Summary of Rights provides additional
information about your rights.
You have the right to obtain an additional free copy of the enclosed
report if you request it from SecurTest, Inc. within sixty days of when
you receive this notice. The contact information for SecurTest is:
All information must be completed, as it benefits you!
Your EMAIL ADDRESS:
You can create free emails at www.gmail.com, among other websites
Your First Name
Your Middle Name, if any
Your Last Name
Your Maiden Name, if any
Your Social Security Number
Your Date of Birth (mm/dd/yyyy)
Your Street Home Street Address:
Your City
Your State
Your ZIP Code:
Your Home Phone #, if any with AREA CODE:
Your Cell Phone #, if any with AREA CODE:
What is the SecurHomeland Report # (which is the file name) or listed on page 1 of the report. You can also list your social security number:
What is the name of the organization/employer or prospective employer requesting the report on page 1:
Q1a. Did you authorize this report?
Yes
No
Q1. Is the criminal history report your criminal history?
Yes
No
Some of it is
Q2. Is this criminal history report accurate?
Yes
No
Some of it is
Q3. I have criminal convictions that are not on this report.
Yes
No
Q4. I have been convicted of a misdemeanor involving violence.
Yes
No
Q5. I have been convicted of a felony involving violence.
Yes
No
Q6. I have been convicted of a felony in the last 7 years.
Yes
No
Q7. I am on probation or parole.
Yes
No
Q8. If an applicant for employment, I no longer wish to be considered for employment and withdraw my employment application.
Yes
No
Q9. Answer only if you are an applicant for employment and have a criminal record. I should be considered for employment despite my criminal record.
Yes
No
It's not my record
It's not my record
Q10. I did not truthfully answer the question on the employment application about having a criminal conviction record.
Yes
No
I have no criminal convictions that I should have reported on the employment applicattion
Q11. Answer this question only if you have a criminal record. Describe which criminal records by date and case #, if listed, ARE NOT yours. (We search county, state and federal courts to verify records that you say are not yours. Untruthfulness is grounds for not being hired or terminated. Type/Print in detail your answer.
Q12. Answer this question only if you have a criminal record. Please explain why the employer should consider your employment application (or employment status if already employed by the employer) and what you have done to better yourself despite your past criminal record. Type in detail your answer.
I have carefully reviewed this information and certify that it is true and correct. By clicking on Submit - Finished, I hereby indemnify and forever hold harmless SecurTest, Inc., its strategic partners, and my prospective or current employer from any and all claims arising out of my validating this information with my answers. My answers will become part of my record to help clarify, correct or validate my biographical information, which is exclusively owned by SecurTest, Inc.
Type your FULL name as your Electronic Signature
Customer Service Questions
SecurTest, Inc.
1720 Epps Bridge Parkway, Suite 108-380
Athens, GA 30606
800-445-8001 Toll Free
813-888-8000
815-550-8821 Fax
E-Mail customerservice@securtest.com
http://www.securtest.com
Copyright © 2009 SecurTest, Inc. - All Rights
Reserved. Patent Pending.
(SecurHomeland and iReviewNow are copyright, trademarked, patent pending proprietary business process that may not be used or copied unless a registered customer/client of SecurTest or without written consent from the Chief Executive Officer of SecurTest, Inc.)
