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Thank you for considering Fidelifacts / Metropolitan NY, Inc. to assist you with your information needs. Please fill out the form below and a representative will contact your shortly to assist you with answering questions and/or finalizing your service signup.
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Company/Organization: *
PLEASE Use only characters or numbers,
no comma or periods.
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Street Address: *
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City, State, and Zip: *
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Website Address:
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Type of Organization: *
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Are you a Non-Profit Organization? *
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Describe the Nature of your Business: *
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How many years have you been in business?
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How many employees do you have?
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How many New Hires per year?
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How many Locations do you have?
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Name: *
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Title:
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Phone: *
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Email: *
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Best time to contact you?
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Are you the person responsible for making this decision for your company?
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If not, please tell us who is:
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Name: *
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Title
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Phone: *
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Fax:
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Email: *
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Billing street address:
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City, State, and Zip:
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Do you currently perform background checks?
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Reason for changing current service:
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What time frame are you looking to begin screening services with us?
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Projected Number of Applicants to be screened annually:
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How did you hear about us?
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Intended Use of the Information to be Provided: *
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EXHIBIT A
FROM: THOMAS W. NORTON, PRESIDENT
SUBJECT:
FAIR CREDIT REPORTING ACT (FCRA) PL 91-508
CONSUMER CREDIT REPORTING REFORM ACT OF 1996 (CCRRA) PL-104-208 GENERAL BUSINESS LAW OF NEW YORK (CH 867-GBL-NY-1977)
DRIVER PRIVACY PROTECTION ACT (DPPA) 18 U.S.C. SECTION 2721 ET.SEQ.
In order to comply with the above statutes, we are required to have a statement from each of our clients to the effect that reports ordered from Fidelifacts/Metropolitan New York, Inc., which are covered by the above, will be used only for permissible purposes as specified below.
For ease of handling, please read and certify compliance with the statement below by affixing your signature. Forward a copy to us and retain a copy for your files.
If you have any questions regarding the Fair Credit Reporting Act, The Consumer Credit Reporting Reform Act of 1996 or the General Business Law of New York or the DPPA call our toll-free information line at:
800 678-0007
The consumer reports or investigative consumer reports ordered by our firm from Fidelifacts/Metropolitan New York, Inc. will be used only for pre-employment screening, a permissible purpose as outlined in the Fair Credit Reporting Act (PL 91-508), The Consumer Credit Reporting Reform Act of 1996 and the General Business Law of New York (CH 867-NY-1977).
Our firm certifies that it will comply with the Reform Act’s disclosure and adverse action requirement and that the information will not be used in violation of any applicable Federal or State equal opportunity law or regulation nor will it be re-sold to any third party.
Signed : __________________________________________ Date _______________________
Print Name: __________________________________________
Title: __________________________________________
Company: __________________________________________
Address: __________________________________________
Reports will be used only for: Employment Screening
Please Note: Any company or person who knowingly obtains a consumer report under false pretenses or without a permissible purpose will be subject to damages. In these circumstances, the company or person will be liable to both the consumer reporting agency and the applicant or employee for their actual damages sustained or $1,000, whichever is greater.
In addition, any company or person that willfully fails to comply with the statute will be liable to the applicant or employee for actual damages, punitive damages, costs and attorney’s fees, although the Reform Act limits actual damages in this situation to an amount not less than $100 and not more than $1,000.
Finally, if an unsuccessful motion, pleading or other paper is filed in “bad faith or for purposes of harassment,” the Reform Act will award reasonable attorney’s fees to the prevailing party. A copy of this document should be kept on file for 5 (five) years.
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Fields with a "*" Must be Completed. |
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Disclaimer:
By clicking the SUBMIT button above, you are signing your legal electronic signature and are thus agreeing to be bound and abide by Fidelifacts / Metropolitan NY, Inc.'s Terms and Conditions, and any applicable laws.
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