Please note: Sample forms should NOT be construed as legal advice or counsel. Employers should consult their attorneys about their compliance responsibilities under the FCRA and applicable state law. Scherzer International disclaims any warranties, responsibility, or damages associated with or arising from the information provided in this form.


As highlighted in our client alert, the New York Clean Slate Act mandates that employers provide certain notices to applicants if an employment-related background screening report contains criminal record information. To assist our clients in meeting this requirement, we prepared a sample form which is linked below.

With any background report that contains a criminal record, we will include this form, the NYS Correction Law Article 23-A, and the Summary of Consumer Rights. You will need to forward the report and the notices to the applicant.

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