Fill and Sign the Disclosure and Authorization for Consumer Reports and Form

Disclosure and Consent for a Consumer andInvestigative Report and Release Authorization I. I understand that in connection with my application for employment an investigative consumer report will be requested. This investigative consumer report will contain information as to my character, general reputation, personal characteristics or mode of living. This investigative consumer report will include, but is not limited to, a criminal background history. It may also include but is not necessarily limited to, verification of current and previous employment, verification of educational credentials,professional reference verification, credit report, and motor vehicle report. The investigative consumer report will be requested from the following Consumer Reporting Agency: _______________________________________________________________ (Name and Address of Consumer Reporting Agency)II. I understand that according to the Federal Fair Credit Reporting Act (FCRA), prior to taking an adverse action based, in whole or in part, on the information contained in the consumer report, a copy of the consumer report as well as a written summary of my rights under the FCRA will be provided to me. Upon written request, within a reasonable period of time after my receipt of this disclosure, a complete and accurate disclosure of the nature and scope this investigative consumer report, which may involve personal interviews with sources such as neighbors, friends and associates, will be made to me. This disclosure shall be made in writing no later than five days after the date on which the request for such disclosure was received or such report was first requested, whichever is later.III. The information requested will be used in compliance with the FCR, the FederalAmericans with Disabilities Act (ADA) and/or any other applicable federal or state laws. I understand that if I am denied employment because of information contained in whole or in part, in my consumer report I have the right to be notified and given the name and address of the agency or source that provided the information.IV. I hereby authorize, without any reservation, any law enforcement agency, school, employer, reference, information service bureau, institution, or insurance company contacted by Inquest, Inc. or its agents, to furnish the information described in Section I.V. I understand that a FAX or photographic copy of this release shall be valid as the original.VI. I hereby release the agents and employers and all other persons, agencies, and entities providing information or reports about me from any and all liability arising out of the request for or release of any of the above-mentioned information or reports.VII. I have read and understand this Disclosure and Consent form. By my signature below, I consent to the release of a consumer and/or investigative consumer report, as defined above, in conjunction with my application for employment. VIII. I understand that my consent will apply throughout my employment, to the extent permitted by law, unless I revoke or cancel my consent by sending a signed letter or statement to the company at any time.Witness my signature this the _____ day of _________________, 20____._____________________________ _____________________________(Signature of Applicant) (Signature of Prospective Employer)_____________________ _____________________(Printed Name of Applicant) (Printed Name of Prospective Employer)