Background Information Form must be mailed in, due to the signature requirement. Please mail to The River Network 10232 S. 230th East Ave. Broken Arrow, Oklahoma 74014
However, please pay the $50.00 processing fee below
DISCLOSURE AND AUTHORIZATION
[IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION]
DISCLOSURE REGARDING BACKGROUND INVESTIGATION
The River (The Company) may obtain information about you for credentialing purposes from a third party consumer reporting
agency. Thus, you may be subject of a "consumer report" and /or an "investigative consumer report" which may include
information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve
personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information
regarding your criminal history. You have the right, upon written request made within a reasonable time after receipt of this
notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature
and scope of the most common form of investigative consumer report obtained with regard to applicants for credentialing is an
investigation into your criminal history conducted by LexisNexis Screening Solutions Inc, P.O. Box 105108, Atlanta, GA 30348-
5108,1-800-845-6004. The scope of this notice and authorization is all-encompassing, however, allowing the Company to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your credential to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.
New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any
investigative consumer report requested by the Company by contacting the consumer reporting agency identified above
directly.
ACKNOWLEDGMENT AND AUTHORIZATION
I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR
RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents.
I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" by The River at any time after
receipt of this authorization and throughout the time I have a credential with The River, if applicable. To this end, I hereby
authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or
university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by LexisNexis Screening Solutions Inc., P.O. Box 105108, Atlanta, GA 30348-5108,1-800-845-6004, another outside organization acting on behalf of the Company, and/or the Company itself. I agree that a fax,
electronic or photographic copy of this Authorization shall be as valid as the original.
New York applicants only: By signing below, you also acknowledge receipt of Article 23-A of the New York Correction
Law.
Minnesota and Oklahoma applicants only: Please check this box if you would like to receive a copy of a consumer
report if one is obtained by the Company.
California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING
BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box below if you would like to receive
a copy of an investigative consumer report at no charge if one is obtained by the Company whenever you have a right to
receive such a copy under California law.
