I want to become a(n)...

Application

IF YOU ARE A STUDENT, THIS IS NOT YOUR APPLICATION! CLICK HERE TO COMPLETE A STUDENT APPLICATION.

First Name: Last Name: Address:City: County where you plan to mentor:State: Zip: Gender: Social Security Number*: Date of Birth:Email: Home Number: Cell Number: Employer: Work Number: 1st Choice of High School (if your HS is not listed, please email graham@tnachieves.org):2nd Choice of High School:Educational Attainment: Post-Secondary Institution Attended: Number of Students Willing to Mentor:Additional Opportunities to Assist tnAchieves (Select all that apply): Assist tnAchieves staff at TN Promise Meetings Provide TN Promise students with job shadowing opportunities within your organization Share mentoring tips as part of tnAchieves Monday emails How did you hear about us?:
Mentor Name: Mentor County:
Name of Event:
Name of Orgainization:
Type:Please Identify the name fo the media organization (Ex. the Tennessean, Twitter, WBIR, etc):
Email Source (Ex. Chamber, Church, etc):
Specify:
Do you know a person, organization, or business we could visit to connect with potential tnAchieves mentors? If so, please provide their information: Name of Person/Org/Business Contact Information (Phone and/or Email address): Please type the word below: captcha My signature indicates that the information I have provided is true to the best of my knowledge. I agree to allow the program to confirm all information listed and to conduct a criminal records check every two years that I volunteer with the program. tnAchieves will not perform a credit check. I have read and understood the program’s responsibilities for assuming my role as a tnAchieves mentor and agree to commit to the following: a one hour mentor training in the fall of 2015, a one hour team meeting in March, a one hour team meeting in September, to assist the students with any college related questions or concerns, and to provide encouragement to ensure the students reach their full potential.

As a part of our volunteer application process you must successfully complete a background check. In order to make this process quick and easy, tnAchieves requires that you complete the following request. Our background check provider (Employment Screening Services) requires you to read and acknowledge the following in order to generate a report. By providing your consent electronically, it can be safely and securely transmitted to our background check vendor. This enhanced process can remove days of waiting from the overall process. If you have any questions, please call Graham Thomas at 615-604-1306.

Thank You,
TN Achieves

Consumer Disclosure:

Employment Screening Services requests that we provide documents, notices, and disclosures and that we obtain your signature. This electronic transaction is provided by tnAchieves in order to obtain your signature electronically and complete a background check.

Scope of Consent:

You are agreeing to receive electronic notices and disclosures, and provide electronic signatures over the course of your relationship with tnAchieves. You are also agreeing to conduct transactions with tnAchieves electronically. tnAchieves will provide your information to Employment Screening Services (ESS), tnAchieves’ background check service, who will run a criminal history and sex offender registry report. You may at any point withdraw your consent by following the procedures described below. By proceeding forward and signing this document you are agreeing that you have reviewed the consumer disclosure information and you consent to transact business using electronic communications, to receive notices and disclosures electronically, and to utilize electronic signatures in lieu of using paper documents. You are not required to receive notices and disclosures electronically or sign documents electronically. If you prefer not to do so, you may withdraw your consent at any time as described below.

By proceeding forward and signing this document you are agreeing that you have reviewed the consumer disclosure information, and you consent to transact business using electronic communications, to receive notices and disclosures electronically, and to utilize electronic signatures in lieu of using paper documents.

You are not required to receive notices and disclosures electronically or sign documents electronically. If you prefer not to do so, you may withdraw your consent at any time as described below.

Paper Copies:

At the conclusion of this transaction, if you would like paper copies of documents or disclosures, please contact Kellye Coleman with tnAchieves at 540-718-3303 or kellye@tnachieves.org. If you wish to conduct this transaction with paper copies in lieu of electronic documents, you may close this web browser and contact Kellye Coleman with tnAchieves at 540-718-3303 or kellye@tnachieves.org. Please note: the decision to conduct this transaction electronically is solely between you and tnAchieves.

If you wish to conduct this transaction with paper copies in lieu of electronic documents, you may close this web browser and contact the person who asked you to consent to a background report. Please note: the decision to conduct this transaction electronically is solely between you and the person who requested this background report.

Withdrawal of Consent:

You may withdraw your consent to an electronic signature and the completion of a background check, and to receive electronic documents, notices, and disclosures at any time. In order to withdraw consent, you must notify tnAchieves that you wish to withdraw consent and receive all future documents, notices, and disclosures in paper format. If, after withdrawing consent, you decide to proceed forward and utilize the electronic transaction system, you are once again consenting to a background check, and to receive documents, notices, and disclosures electronically.

Required Hardware and Software Requirements:

Web Browsers:
•Internet Explorer 5.0 or above;
•Google Chrome 26 or above;
•Netscape Navigator 4.5 to 4.77, 6.1 or above;
•Firefox 1.5 or above.

Email:

  • Access to a valid email account.

Acrobat Reader:

  • 5.0 or greater.

Windows

  • Pentium-class processor;
  • Microsoft Windows 98 Second Edition, Windows Millennium Edition, Windows NT 4.0 with Service Pack 5 or 6 (Service Pack 6 recommended), Windows 2000, Windows XP Professional or Home Edition, Windows 8;
  • 64MB of RAM;
  • 30MB of available hard-disk space (an additional 60MB is needed temporarily during installation).
  • Macintosh
  • PowerPC processor;
  • Mac OS 9.1, 9.2, or 9.2.2 or Mac OS X v.10.1.3, 10.1.5, or 10.2;
  • 64MB of RAM;
  • 30MB of available hard-disk space (an additional 60MB is needed temporarily during installation);
  • HFS formatted hard drive.

I agree to conduct this transaction electronically

Disclosure of Procurement of Consumer Report

PLEASE BE ADVISED that TN Achieves will obtain information about you from a Consumer Reporting Agency in order to evaluate your eligibility for the purpose of utilizing your volunteer services. Thus, you may be the subject of a Consumer Report or an Investigative Consumer Report.

These reports may include credit reports, credit history information, employment history and reference checks, criminal and civil history information, motor vehicle records and moving violation reports, sex offender status reports, education verification, professional licensure verification, drug testing, Social Security Verification, and information concerning workers’ compensation claims. Credit history will only be requested in compliance with applicable federal and/or state laws. You should carefully consider whether to authorize the procurement of a report.

PLEASE NOTE that tnAchieves only runs and reviews criminal history and sex offender registry data.

PLEASE BE FURTHER ADVISED that you have the right, upon written request to TN Achieves and made within a reasonable time after receipt of this notice, to obtain a complete and accurate disclosure of the nature and scope of any such report. Furthermore, you have the right to request from TN Achieves a written summary of the rights of a consumer prepared pursuant to the Fair Credit Reporting Act, 15 U.S.C. § 1681g(c).

I acknowledge I have read the foregoing disclosure.

Authorization for Release of Information

I AUTHORIZE tnAchieves to obtain consumer reports and/or investigative consumer reports about me at any time after receipt of this Authorization and, if my services as a volunteer are accepted, throughout my service to them.

To this end, I direct and authorize, without reservation, any person or entity, including but not limited to, any corporation, company, business, law enforcement agency, administrator, city, county, state or federal agency, institution, school or university (public or private), information service bureau, employer, past or present, or insurance company to furnish, supply, and release any and all information regarding myself to ESS, Inc., 2500 Southlake Park, Birmingham, AL 35244, toll free 866.859.0143, www.es2.com, or its subcontractor or another outside organization acting on its behalf.

The term “background information” includes, but is not limited to, credit information and history, employment history, reference checks, criminal and civil history information, motor vehicle records, moving violation reports, sex offender status information, credit reports, education verification, professional licensure verification, drug testing, information related to my Social Security number, and information concerning workers’ compensation claims.

PLEASE NOTE that tnAchieves only runs and reviews criminal history and sex offender registry data.

I agree that a facsimile, electronic or photographic copy of this Authorization shall be as valid as the original.

I understand I can view ESS’s Privacy Policy on its website, www.es2.com.

I AUTHORIZE tnAchieves ("The “End User”) to obtain consumer reports and/or investigative consumer reports about me at any time after receipt of this Authorization and, if my services as a volunteer are accepted, throughout my service to End User.

Please Enter Your Initials Here

Summary of Rights

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

  • You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.
  • You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
    • a person has taken adverse action against you because of information in your credit report;
    • you are the victim of identity theft and place a fraud alert in your file;
    • your file contains inaccurate information as a result of fraud;
    • you are on public assistance;
    • you are unemployed but expect to apply for employment within 60 days.
  • In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.
  • You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.
  • You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.
  • Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.
  • Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.
  • Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.
  • You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.
  • You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).
  • You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.
  • Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General.


For information about your federal rights, contact:

1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates
b. Such affiliates that are not banks, savings associations, or credit unions also should list,
(a) Consumer Financial Protection Bureau 1700 G. Street N.W. Washington, DC 20552
(b) Federal Trade Commission: Consumer Response Center – FCRA in addition to the CFPB: Washington, DC 20580 (877) 382-4357

2. To the extent not included in item 1 above:
a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks
b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and Insured State Branches of Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act
c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations
d. Federal Credit Unions
a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050
b.Federal Reserve Consumer Help Center P.O. Box. 1200 Minneapolis, MN 55480
c. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106
d. National Credit Union Administration Office of Consumer Protection (OCP) Division of Consumer Compliance and Outreach (DCCO) 1775 Duke Street Alexandria, VA 22314

3. Air carriers
Asst. General Counsel for Aviation Enforcement & Proceedings
Aviation Consumer Protection Division Department of Transportation 1200 New Jersey Avenue, S.E. Washington, DC 20423

4. Creditors Subject to the Surface Transportation Board
Office of Proceedings, Surface Transportation Board
Department of Transportation 395 E Street, S.W. Washington, DC 20423

5. Creditors Subject to the Packers and Stockyards Act, 1921
Nearest Packers and Stockyards Administration area supervisor

6. Small Business Investment Companies
Associate Deputy Administrator for Capital Access United States Small Business Administration 409 Third Street, S.W., 8th Floor Washington, DC 20549

7. Brokers and Dealers
Securities and Exchange Commission 100 F Street, N.E. Washington, DC 20549

8. Federal Land Banks, Federal Lank Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090

9. Retailers, Finance Companies, and All Other Creditors Not Listed Above
FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center – FCRA Washington, DC 20580 (877) 382-4357

PLEASE NOTE that tnAchieves only runs and reviews criminal history and sex offender registry data.

I have read and understand my summary of rights.

*tnAchieves does not request a credit report and only processes a criminal records and sex offender registry report.

 

* Required for background check

I am currently a...

I want to become a(n)...

I see kids every day who never thought college was possible for them, but are now excitedly scheduling their classes for next year. It's been a thrill to be a part of it!
- Becca, Warren County mentor
I really enjoy being a mentor, it is a great experience for me. I have received nothing but positive feedback from my students and their parents about the program.
- Floriana, Robertson County mentor
As the only person in my family to ever go to college, tnAchieves has made it easier for me to understand what I need to do to succeed.
- Central H.S. Student
tnAchieves introduced me to my mentor, Charlee, who helped me get on track and kept me focused. With her help, I was able to realize that anything was possible.
- Fulton H.S. Student
The students’ desire for help was an eye-opener. I did not realize that they would want, need, and appreciate my help as much as they did!
- Olivia, Hancock County mentor and tnAchieves Ambassador
I’m very proud to be a part of the history being made right in front of our eyes.
- Benny, Lewis County mentor
All my life I always said that I would be the first in my family to make it to college and graduate. tnAchieves is helping my dream come true.
- Austin East H.S. Student
Going to college would be a milestone that I can not hope to reach without the help of tnAchieves.
- Powell H.S. Student
I believe the students really get it now, and know that there are people who are invested in their futures
- Charles, Shelby County mentor