DISCLOSURE AND AUTHORIZATION REGARDING PROCUREMENT OF BACKGROUND REPORTS

It is recognized and understood that the Fair Credit Reporting Act provides that anyone "who knowingly and willfully obtains information on a consumer from a
consumer reporting agency under false pretenses" shall be fined not more than $2,500 or imprisoned not more than a year, or both.

In connection with my application for EMPLOYMENT (including a contract for services), I understand that investigative background inquiries are to be made on me which may include criminal convictions, motor vehicles, and other reports. These reports may include information as to my character, work habits, performance, education, and experience along with reasons for termination of employment from previous employers. Further, I understand that you will be requesting information from various Federal, State, and other agencies which
maintain records concerning my past activities relating to my driving, credit, criminal, civil and other experiences. If I include a current employer for verification, I may jeopardize my position within that company.
I authorize without reservation, any party or agency contacted to furnish the above-mentioned information and release all parties involved from any liability and responsibility for doing so. I hereby consent to obtain the above information from BACKGROUND SOURCE INT'L and/or any of their licensed agents. This
authorization and consent shall be valid in original, fax, or copy form. I further authorize the ongoing procurement of the above-mentioned reports at any time during my employment (or contract).