A3 Smarthome — Background Check Authorization

A³

Smarthome

0 / 7

Form ID Generating…

Opened —

IP Captured Detecting…

User Agent —

Section 01

Applicant Information

Full Legal Name *

Required field

Date of Birth *

Required field

Last 4 of SSN *

4 digits required

Current Street Address *

Required field

City *

Required

State *

Required

ZIP *

Required

Phone Number *

Required field

Email Address *

Valid email required

Driver's License Number

Issuing State

Position / Role Applying For *

Required field

Section 02

Nevada & Federal Disclosure

This disclosure is made pursuant to the federal Fair Credit Reporting Act (FCRA), 15 U.S.C. § 1681 et seq., and Nevada Consumer Reporting statutes, NRS Chapter 598C. This is a standalone disclosure document — no extraneous terms are included, in compliance with 9th Circuit requirements.

A3 Smarthome, operating under license holder Clifton Wayne Jordan, may obtain one or more consumer reports and/or investigative consumer reports about you from a consumer reporting agency (CRA) for employment, contracting, or engagement screening purposes.

CRA Name

CRA Phone

Section 03

Scope of Investigation

The background investigation may include the following. Review each item carefully.

Criminal history — Federal, state, and county. Arrests without conviction limited to 7-year lookback (NRS 598C). Convictions report without time limit (NV SB 409, 2015).
Sealed records (NRS 179.245) — Will NOT be requested, reported, or considered. You are not required to disclose sealed records and may lawfully deny their existence per NRS 179.285.
SSN trace and identity verification.
Motor Vehicle Records (MVR) — Required for field, driving, or site-access roles.
Credit history — Only where NRS 613.570 criteria are met. Separate notice will be provided.
Employment & education verification — No time limit.
Trade license & contractor credential verification (NV State Contractors Board as applicable).
Reference checks — Character, professional performance, and conduct.
Federal sanctions — OFAC watchlist and GSA debarment screening.
NOTE: NV law (NRS 613.570) prohibits use of NV Dept. of Public Safety Sex Offender Registry for employment. Registry data will NOT be used.

Nevada does NOT carry the FCRA $75,000 salary exception. Reporting limits apply regardless of compensation: non-conviction adverse info / liens / civil judgments — 7 years; bankruptcies — 10 years.

Section 04

Your Rights Under FCRA & Nevada Law

Right to know if a consumer report was used against you in an employment or contracting decision.

Right to a free copy of your consumer report from the CRA within 60 days of any adverse action notice.

Right to dispute inaccurate or incomplete information directly with the CRA.

Right to place a security freeze on your credit report, prohibiting release without your express authorization.

Right to seek actual damages, statutory damages ($100–$1,000/violation), punitive damages, and attorney's fees under FCRA § 1681n/§ 1681o.

Right to file a complaint with the Nevada Labor Commissioner (775-684-1890) for illegal background check or adverse action based on inaccurate information.

Sealed records protection (NRS 179.245) — Not required to disclose; cannot be lawfully reported or used against you.

A Summary of Your Rights Under the Fair Credit Reporting Act will be provided separately as required by law.

Section 05

Credit Information Notice (NRS 613.570)

Nevada law restricts employer use of credit reports. A credit report will ONLY be obtained if one or more of the following applies. Check all that apply for this position:

Required by state or federal law for this position. Reasonable belief the applicant engaged in illegal activity related to financial capacity. Credit information is directly and substantially related to the duties of the position (fiduciary, financial, or asset-control role). N/A — Credit report will NOT be obtained for this position.

Section 06

Authorization & Release

I hereby authorize A3 Smarthome, operating under license holder Clifton Wayne Jordan, and its designated agents, representatives, and contracted consumer reporting agencies to conduct a thorough investigation and obtain one or more consumer reports and/or investigative consumer reports on my background, including but not limited to criminal history, driving records, employment history, education, professional licenses, references, financial history (where applicable per NRS 613.570), federal sanctions, and any other legally permissible records.

I release from liability all persons, agencies, and organizations that furnish information in response to this authorization. I understand this consent is valid for the initial screening and may be used for re-screening during the period of my engagement, consistent with applicable law.

I understand and acknowledge that:

I may refuse to consent and A3 Smarthome may choose not to hire or engage me as a result.
Sealed records under NRS 179.245 need not be disclosed and cannot be used against me.
Inaccurate information in any consumer report may be disputed directly with the CRA.
If adverse action is taken, I will receive a pre-adverse action notice, a copy of the report, a summary of my FCRA rights, and an opportunity to dispute before a final decision is made.

I certify that all information I have provided in connection with this background check process is true, complete, and accurate. I understand that misrepresentation or material omission may disqualify me or result in termination of engagement.

Section 07

Electronic Signature

By signing below, you acknowledge that you have read, understood, and consent to all terms above. Your electronic signature carries the same legal weight as a handwritten signature under the Electronic Signatures in Global and National Commerce Act (E-SIGN, 15 U.S.C. § 7001) and the Nevada Uniform Electronic Transactions Act (NRS Chapter 719).

Typed Full Name (to confirm identity) *

Must match full legal name above

Date *

Required

Draw Your Signature Below *

Draw with mouse, finger, or stylus

Signature is required

Live Audit Trail — Legal Backbone

FORM ID

—

TIMESTAMP (OPEN)

—

TIMESTAMP (SUBMIT)

Pending submission…

IP ADDRESS

Detecting…

GEOLOCATION

Requesting…

DEVICE / BROWSER

—

SCREEN RESOLUTION

—

TYPED NAME MATCH

Waiting for input…

SIGNATURE CAPTURED

Not yet signed

FORM CHECKSUM

Pending submission…

Submitting locks this form. A timestamped PDF report will be generated for your records and returned to A3 Smarthome. This action cannot be undone.

✓

Authorization Submitted

Your background check consent has been recorded and transmitted to A3 Smarthome.
Save your receipt below for your records.

Submission Receipt

FORM ID

—

SUBMITTED BY

—

TIMESTAMP

—

IP ADDRESS

—

GEOLOCATION

—

FORM CHECKSUM

—

⚙ How to Deploy & Send This Form

Step 1 — Host it free (5 min):
Go to netlify.com/drop → drag the A3_BGCheck_ESign_Form.html file onto the page → Netlify gives you a live URL instantly (e.g. https://radiant-choux-a3bgc.netlify.app).

Step 2 — Wire up the email (one-time setup):
1. Go to formspree.io → free account → New Form → set destination to [email protected]
2. Copy your Form ID — looks like xpwzgkla
3. Open the HTML file in Notepad or TextEdit, find REPLACE_WITH_YOUR_FORMSPREE_ID, paste your ID in its place, save
4. Re-drag the updated file onto Netlify — done. Every signed form now emails you the full audit record automatically.

Step 3 — Send to reps (pick any method):
• Text: Paste the Netlify URL directly in a text message
• Email: Drop the link in your onboarding email
• QR code: Go to qr.io, paste the URL, download — print it or embed it in your offer letters

What hits your inbox on every submission:
Subject line: [A3 BGC] Consent Signed — [Name] — [Form ID]
Body: Full audit report — name, DOB, last 4 SSN, IP address, geolocation, device fingerprint, typed name match, SHA-256 checksum, timestamp, and all consent fields. That is your non-repudiation chain.