Background Check Authorization Form: Sample for Employers
This sample background check authorization form records an applicant’s written consent to employment screening.
First, review the wording below. Then, use it with a separate disclosure, as the FCRA requires.
Sample only: This form is a starting point, not legal advice. Therefore, ask your legal counsel to review it before use.
What Is a Background Check Authorization Form?
A background check authorization form is the document an applicant signs to permit a background check.
Under the Fair Credit Reporting Act (FCRA), an employer needs this written permission first. Specifically, the rule applies when you order a report from a background screening company. However, the authorization is not the same as the disclosure. The disclosure tells the applicant that you may order a report. In contrast, the authorization records the applicant’s consent.
What the FCRA Requires Before a Background Check
The FTC lists three steps before you order a report. Therefore, complete all three for every applicant.
- 1. Written disclosureFirst, tell the applicant in writing that you may use the report for employment decisions. The notice must be in a stand-alone format.
- 2. Written authorizationNext, get the applicant’s written permission. For ongoing checks, say so clearly and conspicuously.
- 3. CertificationFinally, certify to the screening company that you gave the notice and got permission. Also certify that you will not misuse the report.
Keep extra wording out of the disclosure
Courts read the stand-alone rule strictly.
For example, the Ninth Circuit rejected a disclosure that also carried state law notices (K&L Gates on Gilberg).
Consequently, this sample places the state and city provisions in the authorization instead.
Sample Background Check Authorization Form
Read the full sample below. In addition, each blank line shows where the employer or the applicant writes.
Acknowledgment and Authorization for Background Check
Sample form
I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION (View Disclosure) and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT (view the summary of your rights) 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
Employer’s Name:
at any time after receipt of this authorization and, to the extent permitted by law, throughout my employment, 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:
BCS Background Screening LLC, 1172 South Dixie Hwy #257, Coral Gables, FL 33146. Telephone (800) 661-0278. Privacy practices: usabackground.com/privacy/
and/or Employer.
I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.
Investigative consumer reports: If the Employer obtains an investigative consumer report, I understand that I have the right, upon written request made within a reasonable time, to request a complete and accurate disclosure of the nature and scope of the investigation.
State and City Provisions
California, Minnesota and Oklahoma residents/applicants only: Please check here if you would like to receive a free copy of a consumer report or investigative consumer report if one is obtained by the Employer.
New York residents/applicants only: Upon request, you will be informed whether or not a consumer report was requested by the Employer, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. You have the right to inspect and receive a copy of any investigative consumer report requested by the Employer by contacting the consumer reporting agency identified above directly. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law (view Article 23-A).
New York City residents/applicants only: You acknowledge and authorize the Employer to provide any notices required by federal, state or local law to you at the address(es) and/or email address(es) you provided to the Employer.
Washington State residents/applicants only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
Los Angeles residents/applicants only: View the Notice to Applicants and Employees for Private Employers.
San Francisco residents/applicants only: View the San Francisco Fair Chance Ordinance notice.
Electronic Signature
I consent to sign and receive these documents electronically, and I may ask the Employer for a paper copy. I understand that by either signing my name or, typing my name and my Last four SSN, and by clicking on “I ACCEPT” below, that I am electronically signing the above document. I understand that my electronic signatures will be binding as though I had physically signed these documents by hand. I agree that a printout of this authorization may be accepted with the same authority as the original.
Print Name: Last 4 digits SSN:
Signature: Today’s Date:
Sample form by BCS Background Screening LLC. Updated October 2026.
State and City Provisions in This Authorization Form
Federal law is only the baseline. Additionally, several states and cities add their own steps. Therefore, this background check authorization form includes eight local provisions.
| Place | What the form includes | Source |
|---|---|---|
| California | A check box to request a free copy of the report. The employer then sends the copy within three business days of receiving the report. | Cal. Civ. Code § 1786.16 |
| Minnesota | The same check box. In addition, the screening company sends the copy within 24 hours, at no charge. | Minn. Stat. § 13C.02 |
| Oklahoma | The same check box, so the applicant can ask for a copy of the report. | Check box in the form |
| New York | The right to learn whether the employer requested a report. Moreover, the applicant acknowledges receipt of Article 23-A. | N.Y. Correction Law Art. 23-A |
| New York City | Consent to receive required notices at the postal and email addresses the applicant gave. | Provision in the form |
| Washington State | The right to request a written summary of rights under the Washington Fair Credit Reporting Act. | RCW chapter 19.182 |
| Los Angeles | A link to the city’s notice to applicants and employees for private employers. | Fair Chance Initiative for Hiring |
| San Francisco | A link to the city’s Fair Chance Ordinance information for applicants. | Fair Chance Ordinance |
Other places also set screening rules. Therefore, compare your process with our state by state employment screening laws.
How to Use a Background Check Authorization Form
-
1
Give the Disclosure First
First, hand the applicant the stand-alone disclosure.
Importantly, keep it out of the job application.
-
2
Share the Summary of Rights
Next, provide “A Summary of Your Rights Under the Fair Credit Reporting Act.”
The form asks the applicant to confirm receipt.
-
3
Collect the Signature
Then, have the applicant sign and date the authorization.
Alternatively, collect an electronic signature.
-
4
Order the Report and File the Form
Finally, order the background check only after you have consent.
Afterward, keep the signed form with your hiring records.
Prefer electronic consent? Then, let applicants sign online through our mobile background screening.
Background Check Authorization Form: FAQs
What is a background check authorization form?
It is the document an applicant signs to permit a background check.
Additionally, it shows the employer that the applicant gave written consent.
Is a background check authorization form required by law?
Yes. The FCRA requires written permission before an employer orders a report from a screening company.
Moreover, some states add their own consent rules.
Can the authorization and the disclosure be one document?
Yes. The FTC says the authorization can appear in the same document as the notice.
However, that document must stand alone.
Therefore, this sample keeps the authorization separate from the disclosure.
Can an applicant sign the authorization form electronically?
Yes. This sample supports written or electronic consent.
In addition, it includes a short consent to sign and receive documents electronically.
How long does a background check authorization last?
This sample covers checks at any time after signing and throughout employment, where the law allows.
However, the FTC says you must state that clearly and conspicuously.
State rules differ, so confirm the wording with your counsel.
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Disclaimer: This sample form offers general information, not legal advice. BCS Background Screening LLC does not assume responsibility for its compliant content. Laws change, so consult legal counsel before you use it.