Background Check Authorization Form

(This form is submitted directly to USA Homestays. The information is NOT retained on this website or any USAH server.)

In connection with my application to serve as a Homestay Host Family with USA Homestays, I understand that an “investigative consumer report”, as defined by the Fair Credit Reporting Act, will be requested by USA Homestays for volunteer purposes from Protect My Ministry, Inc., (“Protect My Ministry”), a consumer reporting agency as defined by the Fair Credit Reporting Act.  These reports may include information as to my character, general reputation, personal characteristics or mode of living. They may involve interviews with sources such as my neighbors, friends or associates. The report may also contain information about me relating to my criminal history, credit history, driving and/or motor vehicle records, social security number verification, verification of education or employment history, worker’s compensation (only after a conditional job offer) or other background checks. Such reports may be obtained at any time after receipt of this Disclosure and Authorization and if I serve as a homestay host, as permitted by law and unless revoked by me in writing.  I understand that I have the right, upon written request made within a reasonable amount time after the receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report to Protect My Ministry, Inc., 14499 N. Dale Mabry Hwy., Suite 201 South, Tampa, FL 33618 or 1-800-319-5581. For information about Protect My Ministry’s privacy practices, see www.protectmyministry.com.

Acknowledgement and Authorization

By signing below, I voluntarily and knowingly authorize USA Homestays or its authorized agents to obtain or prepare consumer reports or investigative consumer reports about me.  I acknowledge receipt of a copy of A Summary of Your Rights under the Fair Credit Reporting Act and certify that I have read this Disclosure and Authorization as well as the summary explaining my rights under the Fair Credit Reporting Act.

 

Residents of Minnesota and Oklahoma only:
Under state law you have a right to receive a copy of your consumer report, free of charge, if one is required by USA Homestays. By checking the below box, a copy will be provided to you at the address you provide on this Disclosure and Authorization.
Residents of New York only:
Under state law you have the right to inspect and receive a copy of any investigative consumer report requested by USA Homestays by contacting Protect My Ministry directly. You also acknowledge receipt of a copy of Article 23-A of the New York Correction Law by checking the below box.
Residents of Washington State only:
Under state law you have a right to request a copy of the Washington Fair Credit Reporting Act’s disclosure to consumers (RCW 19.182.070) and a copy of your report by contacting Protect My Ministry directly.
Residents of California and Maine only:
Under state law you have a right to receive a copy of your investigative consumer report and/or consumer credit report, free of charge, if one is requested by USA Homestays. By checking the box below a copy of your report will be provided to you at the address you provide on this Disclosure and Authorization.
Name (Electronic Signature) *
Name (Electronic Signature)
Today's Date *
Today's Date
Address *
Address
Please also list the state that issued the ID.
Phone *
Phone
Date of Birth
Date of Birth
This is for identification purposes only.
Please list any other names you have used in the past.