How to use this template. Print or render Form A and Form B as two separate documents (or two separate pages of an electronic packet, each with its own signature event). Attach the “Summary of Your Rights Under the FCRA” as a third stand-alone document — Neuroscale uses the version published by the Consumer Financial Protection Bureau (CFPB) and updated whenever the CFPB updates its model. Then attach the applicable state-specific addenda based on the candidate’s residence and the position’s work location. Operational handling, vendor (Checkr) configuration, adjudication standards, and adverse-action workflow are described in the Background Checks Procedure; the underlying personnel-security policy is the HR Security Policy.
FORM A — DISCLOSURE REGARDING BACKGROUND INVESTIGATION
This Disclosure is provided as a stand-alone document, separate from any application for employment or other documents, in compliance with 15 U.S.C. § 1681b(b)(2)(A)(i). NEUROSCALE LLC (“Neuroscale” or the “Company”) may obtain information about you from a third-party consumer reporting agency for employment purposes. Thus, you may be the 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, social-security verification, motor-vehicle records (“driving records”), verification of your education or employment history, or other background checks. 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 is an employment-history or educational-history verification. The contact information for the consumer reporting agency that will furnish reports about you is:{{cra_name}} {{cra_address}} {{cra_phone}}The scope of this Disclosure includes potential reports throughout your employment or contractor relationship with Neuroscale, including any pre-employment screening and any subsequent reports obtained for employment purposes (e.g., periodic re-screening for sensitive roles).
Form A continues below — Form A and Form B must be acknowledged separately. Acknowledgment of Receipt of Disclosure I, {{candidate_name}}, acknowledge that I have received this Disclosure and the accompanying “Summary of Your Rights Under the Fair Credit Reporting Act.” Signature: _______________________________ Printed Name: {{candidate_name}} Date: ___________________________________
FORM B — AUTHORIZATION FOR BACKGROUND CHECK
This Authorization is provided as a stand-alone document, separate from Form A. I, {{candidate_name}}, having received and read the Disclosure Regarding Background Investigation provided to me by NEUROSCALE LLC (“Neuroscale”), authorize Neuroscale and {{cra_name}} (the “Consumer Reporting Agency” or “CRA”) to procure consumer reports and/or investigative consumer reports about me for employment purposes in connection with the position of {{position_title}}, including any such reports obtained from time to time during my employment or engagement with Neuroscale. The categories of information that may be requested include, without limitation: {{check_categories}} (e.g., criminal records (federal, state, county, and global watchlists, where lawful), Social Security verification, address history, employment verification, education verification, professional license verification, motor-vehicle records). I authorize, without reservation, any party or agency contacted by Neuroscale or the CRA to furnish the above-mentioned information. I understand that I may withdraw this authorization at any time by giving written notice to Neuroscale, except that withdrawal shall not affect any actions taken in reliance on it before its receipt. A copy of this Authorization shall be as valid as the original. I authorize the use of an electronic signature. Signature: _______________________________ Printed Name: {{candidate_name}} Date: ___________________________________Attachment — Summary of Your Rights Under the FCRA
Note for Neuroscale users: Provided separately as a stand-alone document; copy from the CFPB-published model form (the “Summary of Consumer Rights” required by 12 CFR Part 1022, Appendix K, and 15 U.S.C. § 1681g(c)(1)) at https://www.consumerfinance.gov/. Verify that the version date matches the CFPB’s most recent publication before each batch of mailings — the CFPB updates this form periodically. Do not rewrite or paraphrase. The CRA may also supply the current version directly.
State-Specific Notices and Addenda
Provide each candidate with the addenda corresponding to (i) the candidate’s state of residence and (ii) the state in which the position is based or work will be performed. Attach as additional stand-alone documents.A. California — Investigative Consumer Reporting Agencies Act (“ICRAA”)
In addition to the federal disclosure above, and pursuant to California Civil Code §§ 1786.16, 1786.22, you are notified that: a. An investigative consumer report may be made about you in connection with your application for employment with Neuroscale. b. The report will be prepared by {{cra_name}}, located at {{cra_address}} (telephone {{cra_phone}}). The CRA’s website, where the nature and scope of its investigations and a summary of California rights are described, is published on the CRA’s site. c. The report may include information about your character, general reputation, personal characteristics, and mode of living, obtained from public records and through interviews with personal references. d. You have the right under California law to inspect the files maintained on you by the CRA, in person, by mail, or by telephone (with proper identification), and to receive a copy of the file at no charge if you appear in person, or for a small fee by mail.☐ Check this box if you would like to receive, free of charge, a copy of any investigative consumer report or consumer credit report obtained about you by Neuroscale, to be sent to the address you provide.
B. New York City — Fair Chance Act
Pursuant to the New York City Fair Chance Act (NYC Admin. Code § 8-107(11-a)), Neuroscale will not inquire about your criminal history until after a conditional offer of employment has been extended. If a conditional offer is made and Neuroscale subsequently receives information about your criminal history, Neuroscale will conduct an individualized “Fair Chance Process” assessment under Article 23-A of the New York Correction Law and will provide you with: a. A copy of the consumer report (or, if no report was obtained, a written summary of the criminal-record information considered); b. A written copy of the Fair Chance Notice, including the Article 23-A factors analysis; c. At least five (5) business days to respond, during which the position will be held open.C. New York State — Article 23-A and § 380-c
Pursuant to New York Correction Law Article 23-A and General Business Law § 380-c, you are entitled, upon request, to a copy of any consumer report obtained about you and to a copy of Article 23-A. A copy of Article 23-A is provided as part of this packet upon request to people@neuroscale.ai.D. Massachusetts — CORI Acknowledgment
If a Criminal Offender Record Information (“CORI”) check is conducted under M.G.L. c. 6, § 172, you will be provided with a separate CORI Acknowledgment Form prior to the request, which you must sign. You have the right to receive a copy of any CORI report obtained about you, and Neuroscale will provide you with a copy if Neuroscale takes adverse action based in whole or in part on the report.E. Washington — RCW 19.182
You are entitled, upon written request to the CRA listed above, to a complete and accurate disclosure of the nature and scope of any investigative consumer report Neuroscale requests, along with a written summary of your rights under chapter 19.182 RCW.F. Minnesota — Minn. Stat. § 13C.02
☐ Check this box if you would like to receive a copy of any consumer report Neuroscale obtains about you. The CRA will mail the copy to you within three (3) business days of providing the report to Neuroscale.
G. Oklahoma — 24 Okla. Stat. § 148
☐ Check this box if you would like to receive a copy of any consumer report Neuroscale obtains about you.
H. New Jersey — Opportunity to Compete Act
Pursuant to the New Jersey Opportunity to Compete Act, N.J.S.A. 34:6B-11 et seq., Neuroscale will not inquire into your criminal history during the initial-employment-application process. Inquiries, if any, will occur only after the initial application process has concluded.I. Other States
The Parties acknowledge that additional state laws (e.g., Maine, Maryland, Vermont, Connecticut, Illinois, Oregon, Colorado, Hawaii, the District of Columbia) impose specific disclosure or “ban-the-box” obligations. Neuroscale will provide additional state-specific notices where required by the candidate’s state of residence or work location. Refer to the Background Checks Procedure for the current state-by-state matrix.Variables
| Variable | Description |
|---|---|
{{candidate_name}} | Full legal name of the candidate or contractor |
{{position_title}} | Title of the position for which the candidate is being considered |
{{check_categories}} | Specific categories of information requested for this candidate (e.g., “criminal records, SSN trace, employment verification, education verification”) — must match Checkr package configuration |
{{cra_name}} | Legal name of the consumer reporting agency (Neuroscale’s standard CRA is Checkr, Inc.) |
{{cra_address}} | CRA’s mailing address |
{{cra_phone}} | CRA’s toll-free phone number |
Cross-References
- Background Checks Procedure — adjudication standards, Checkr package configuration, state-by-state matrix, and adverse-action workflow.
- HR Security Policy — personnel-security control objectives and pre-employment screening requirements.
- Adverse Action Letter Templates — pre-adverse and final-adverse notices to be issued where Neuroscale considers or takes adverse action based in whole or in part on a consumer report.
- Onboarding Procedure — workflow that triggers the Disclosure/Authorization step at offer acceptance.
Version history
| Version | Date | Description | Author | Approved by |
|---|---|---|---|---|
| 1.0 | May 8, 2026 | Initial version | Cameron Wolfe | Ishan Jadhwani |