Fill and Sign the Investigative Consumer Report Form

Consent to Investigative Consumer Report Name:       Social Security #:       -       -       Home Phone #:       Driver's License #:       State Issued:       Name as it appears on license:       Date of Birth       Home Address:       City:       State:       Zip:       I hereby give consent for an investigative consumer report to be done on me for ____________________ ___________________________________________________________(purposes) . I hereby authorize, without reservation, any person, law enforcement agency, state agency, former employer, corporation, partnership, limited liability company, credit agency, educational institution, city, state, federal court, military institution, employer or insurance company contacted by ___________________________________________ to furnish any and all information required. I do understand the investigation will include information from law enforcement agencies, state agencies and public records information, such as credit, social security, criminal, motor vehicle and workers' compensation in accordance with the American with Disabilities Act. This report will include information as to my character work habits, performance and experience, along with the reasons for termination of past employment from previous employers. This releases the aforesaid parties from any liability and responsibility for collecting the above information at any time. According to the Fair Credit Reporting Act (Law 91-508) SS 606: A person may not procure or cause to be prepared an investigative consumer report on any consumer unless it is clearly and accurately disclosed to the consumers that an investigative consumer report including information as to his character, general reputation, personal characteristics and mode of living and employment history, whichever are applicable, may be made. I also understand that if I am denied employment because of the consumer investigation, it is my right to have the name of the agency or agencies disclosed to me within the time allowed. This authorization, in original or copy form, shall be valid for this and any further reports or updates that may be requested. Signed: __________________________________ Date: ___________