Notice/authorization and release for the procurement of an investigative report

Name: _____________________________________ (PLEASE PRINT OR TYPE)
I, the undersigned coach/administrator, do hereby authorize THE SOCCER ASSOCIATION OF COLUMBIA by and through its independent contractor, KROLL BACKGROUND AMERICA, INC. (“KBA”), to procure an investigative background report on me.

The above-mentioned report(s) may include, but are not limited to, criminal history records and any other public record.

• I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any investigative report of which I am the subject upon my written request to KBA, if such is made within a reasonable time after the date hereof. I also understand that I may receive a written summary of my rights under 15 U.S.C. § 1681 et.seq.
• I further authorize any person, business entity or governmental agency who may have information relevant to the above to disclose the same to THE SOCCER ASSOCIATION OF COLUMBIA by and through KBA, including, but not limited to any and all courts, public agencies, and law enforcement agencies, regardless of whether such person, business entity or governmental agency compiled the information itself or received it from other sources.
• I hereby release THE SOCCER ASSOCIATION OF COLUMBIA, KBA and any and all persons, business entities and governmental agencies, whether public or private, from any and all liability, claims and/or demands, by me, my heirs or others making such claim or demand on my behalf, for providing an investigative report hereby authorized.
• I understand that this Notice/Authorization Release form shall remain in effect for the duration of my employment/volunteer relationship with the Soccer Association of Columbia.   Additionally, I give permission to investigate any incidents of workplace misconduct, including but not limited to; sexual harassment, for which I am alleged to have been involved during my employment. Further, I certify that the information contained on this Authorization/Release form is true and correct and that my application for either employment or a volunteer position with the Soccer Association of Columbia will be terminated based on any false, omitted or fraudulent information.

Signature: ___________________________________________________

Printed Name (First / Middle / Last) __________________________ Date: ______________

Other Names Used (alias, maiden, nickname)____________________________

Years Used_______________________________

Current Address:_________________________________________________________________
Street/P.O. Box City State Zip Code County Dates

Former Address:__________________________________________________________________
Street/P.O. Box City State Zip Code County Dates

Former Address:__________________________________________________________________
Street/P.O. Box City State Zip Code County Dates

Social Security Number: ________________________________

Daytime Telephone Number:_______________________________

Driver’s License Number:________________________State of Issuance______

Date of Birth*_______________ Gender*______

* This information will enable us to properly identify you in the event we find adverse information during the course of our background search.
© 2002, KROLL BACKGROUND AMERICA, INC, ALL RIGHTS RESERVED

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