Authorization for Release of Information

In connection with, and duration of my employment (including contact for services) with you, I understand that investigative background inquiries are to be made on myself that may include consumer, criminal, driving, academic and other reports. These reports will include information as to my character, work habits, performance and experience. The scope of this notice is authorization allows the employer to obtain consumer reports and investigative consumer reports now and throughout the course of my employment, including contract for services, to the extent permitted by law, unless I revoked my consent by providing written notification to employer.

Further, I understand that employer may be requesting information from various federal, state and other agencies which maintain records concerning my past academic, employment (including worker’s compensation claims), driving, credit, criminal, and civil histories and other experiences. I authorize, without reservation, any party or agency contacted by this employer or it’s agent, info quest, inc. to furnish the above information:

All fields are required.

Name

First Name

Last Name

Previous Last Names

Social Security Number

Date of Birth

DOB is requested to assure accurate retrieval of records.

MM

DD

YYYY

Drivers License Number

State of Issue

Current Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please check if applies

CA, MN, OK, and NY applicants only: please check here to have a copy of your consumer report sent directly to you by Info Quest, Inc.

Mother's Maiden Name

Lived in Puerto Rico? Any research completed in Puerto Rico will need applicant’s mother’s maiden name. I have had an address in Puerto Rico:

Applicant's Signature

Lived in Canada? Please notify HR for additional forms. I understand by signing my name below that I am signing the Authorization form directing the background check, as described above, and I certify that I have read the Disclosure information above. If an investigative consumer report, I have received the FCRA Summary of Your Rights, and if a California resident/applicant, the A Summary of Your Rights Under the Provisions of California Civil Code 1786.22. If a New York applicant/employee, I acknowledge receipt of Article 23-A of the New York Correction Law.

Date

MM

DD

YYYY

The consumer and/or investigative consumer report(s) will be obtained from:

Info Quest Inc., PO Box 15521, Surfside Beach, SC 29587. Info Quest’s information and privacy policy can be found at www.infoquesthr.com