Fill and Sign the Lien Release Form

statefarm.com/agents/career Authorization for Release of Information form instructions On the Authorization for Release of Information form, Agency Career Track candidates should complete the form and check the first two boxes only. The two boxes are: •  Employment consideration, including but not limited to pre-employment screening; consideration for promotion, retention or job reassignment; and compliance with employment-related laws. •  n connection with a possible appointment to serve as a Registered Representative with State Farm VP I Management Corp. The Agency (ESP and EFA) and Independent Contractor sections do not apply to the Agency Career Track candidates. This is proprietary information owned by State Farm®, and it may be lawfully used only as authorized by appropriate Agency management. Z-24972 AOR.2 5-2010 AUTHORIZATION FOR RELEASE OF INFORMATION I, , hereby authorize State Farm Mutual Automobile Insurance Company, its subsidiaries and affiliates (hereinafter referred to as “State Farm®”), and their authorized agents (which may include a consumer reporting agency as defined in the Fair Credit Reporting Act, 15 U.S.C. § 1681a(f)), to obtain an investigative consumer report which may include one or more of the following items: motor vehicle record and drivers license verification, criminal records, prior job performance and employment verification, personal credit report, education verification, and professional license verification, character, general reputation, personal characteristics, mode of living, credit standing, credit capacity and credit worthiness. If being considered for a position requiring sponsorship with the Financial Industry Regulatory Authority, the report will also include FINRA-Central Registration Depository records. This consumer report will be obtained on my person for the purposes indicated below: EMPLOYMENT Employment consideration, including but not limited to pre-employment screening; consideration for promotion, retention or job  reassignment; and compliance with employment-related laws; SECURITIES REGISTRATION SPONSORSHIP WITH SFVPMC In connection with a possible appointment to serve as a Registered Representative with State Farm VP Management Corp;  AGENCY (ESP and EFA) As part of a review of my candidacy to render service as an Emergency Service Program associate (ESP). As part of a review of my candidacy to become an employee of a future agent (EFA). Those authorized to review the ordered  consumer report on my person shall include the personnel in Human Resources and other departments who review these records as well as the agency intern who may become my eventual employer. INDEPENDENT CONTRACTOR As part of a review of my candidacy to render service as an independent contractor 1) Instructor; 2) Claim representative; 3) Consultant; or 4) ; This authorization encompasses the ordering of an investigative consumer report (as defined in the Fair Credit Reporting Act, 15 U.S.C.§ 1681a(e)), which may include interviews with my friends, neighbors, or associates. This authorization also permits any present or former employer, school, police department, financial institution, department of motor vehicles, or other persons or government agencies to furnish information about me in their possession to State Farm or its authorized agents. This authorization may be used multiple times within a 12-month period effective from the date signed for the purposes previously authorized. If there is any inconsistency between this authorization and any applicable legal requirement pertaining to the disclosures contemplated, then this authorization shall be limited to what the law allows. Printed Name Signature Date Driver’s License Number Social Security Number Central Registration Depository (CRD) Number (if applicable) Address City, State, ZIP Code CALIFORNIA, MINNESOTA AND OKLAHOMA RESIDENTS ONLY Under California, Minnesota and Oklahoma law, you have the right to receive a free copy of your consumer report by checking the box below. The consumer reporting agency will directly mail your report to the address indicated above. YES, I am a California resident and would like a free copy of my investigative consumer report. YES, I am a Minnesota resident and would like a free copy of my consumer report. YES, I am an Oklahoma resident and would like a free copy of my consumer report. NO, I would not like a copy of my consumer report. WASHINGTON RESIDENTS ONLY YES, (initials) I am a Washington state resident and I authorize State Farm to obtain a consumer report on my person which includes information pertaining to my credit worthiness, credit capacity, or credit standing. I understand that this information is related to the job for which I am applying or for which I am being considered. Specifically, the job in question implies fiduciary duties for which a person with poor credit might be considered unfit. State Farm is concerned that individual employees with a poor credit record may present an undue risk of misusing company property, including company funds and confidential business information to which they might have access, to resolve outstanding personal credit issues at State Farm’s expense. Printed Name Signature