MD3 Enrollment

By pressing "I Agree" below, I acknowledge that all of the information that I have provided on this application is true, complete, and correct to the best of my knowledge and belief and is provided in good faith.

I further understand that if I believe I have been wrongly identified as a security threat, I will be given the opportunity to contact TSA's Office of Transportation Threat Assessment and Credentialing to address my concerns. I have been informed that redress based on the security threat assessment (STA) will be handled on a case-by-case basis due to the classified and/or security sensitive information that may be involved. TSA will provide information on which the determination was based to me to the extent permitted by law. There may be items that are classified or sensitive security information that TSA cannot release. For the name based security threat assessment, TSA will be the final adjudicator for security threat assessments. The information I will provide on this application is true, complete, and correct to the best of my knowledge and belief and is provided in good faith. I understand that a knowing and willful false statement on this application can be punished by fine or imprisonment or both. (See section 1001 of Title 18 United States Code).

In order to be fingerprinted I give my release and consent for a background check and understand my rights under the Fair Credit Reporting Act (FCRA) In order to be fingerprinted, you must fully read and agree to the following disclaimer:

The information I will provide on this application is true, complete, and correct to the best of my knowledge and belief and is provided in good faith. I understand that a knowing and willful false statement on this application can be punished by fine or imprisonment or both. (See section 1001 of Title 18 United States Code).

Release and Consent for a Background Check

I certify that all answers given here will be true and complete to the best of my knowledge. I authorize the investigation of all matters herein contained and hereby give my EMPLOYER, prospective employer or other entity I have authorized (hereafter referred to as "EMPLOYER") and NATA Compliance Services (hereafter referred to as "AGENT"), permission to contact appropriate parties, and hereby release EMPLOYER or other authorized entity and its AGENT from all liability as a result of such contact. I hereby consent to allow the AGENT to conduct the above stated background checks on me, and to report the results of such a check to EMPLOYER. I understand and authorize the release of all such information to EMPLOYER and AGENT.

I agree that EMPLOYER may, at its sole discretion, deny me employment, require that I be removed from a temporary assignment or discharge me from employment if the information received in the investigation is considered unfavorable by EMPLOYER. Any offer of employment or continuing employment (if currently employed) by EMPLOYER is subject to and conditioned upon EMPLOYER'S review of such information.

In the event of an offer of employment, subsequent employment, and/or continuing employment, I understand that false, misleading or omitted information in my application/background check information shall be grounds for withdrawal of an offer of employment or discharge at any time.

Notice to Applicant/Employee Regarding Consumer Rights
Under the Fair Credit Reporting Act

The Fair Credit Reporting Act (FCRA) governs the activities of consumer credit reporting agencies, as well as the users of the information procured from these agencies. A consumer report contains information on a consumer's (job applicant's) character, reputation, and other personal data. Employers to screen job applicants procure these reports. Employer agrees to comply with all aspects of the Fair Credit Reporting Act and any applicable Federal or State equal employment opportunity law or regulation.

Among other things, the FCRA prohibits Users (Employers) from obtaining consumer reports unless the Employer discloses to the applicant, in writing, (The "REQUEST, AUTHORIZATION, CONSENT AND RELEASE FOR BACKGROUND INFORMATION" form) that such a report may be acquired. This disclosure must be in the form of a document that consists solely of the disclosure that a consumer report may be obtained for employment purposes. This release must also state that if the employer denies employment based on the information from an AGENT report, the applicant may make written inquiry requesting a disclosure of the nature and scope of the investigation.

If an applicant makes such a request, AGENT will supply a complete and accurate disclosure of the nature and scope of the investigation within five days of the request. AGENT will reexamine any item the applicant holds to be incorrect at no additional charge and, if necessary, supply a corrected report to the original requester. AGENT keeps copies of each investigation for a period of not less than one year.

If a consumer reporting agency or user of such information willfully fails to comply with and FCRA requirements, the Consumer Reporting Agency and its agents are responsible to the subject of the report. AGENT complies with all the regulations set forth by the FCRA.

In addition, any individual who knowingly and willfully obtains information from a consumer reporting agency under false pretenses will be fined not more than $5000.00 and imprisoned not more than one year or both.

AGENT complies with and supports all provisions of the Fair Credit Reporting Act (FCRA). We urge all employers to review its restrictions and requirements. The Act's citation is Public Law 91-508, Title 15, U.S.C. Sections 1681, et seq. Please note, particularly, the Permissible Purposes of Reports, as well as requirements on Users of Consumer Reports and Obtaining Information Under False Pretenses.

I have read this release and consent form and understand all of its terms. I execute it voluntarily and with full knowledge of its significance.