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will order a consumer report and/or investigative consumer report (-background check report") on you in connection with your application for employment, or if von are already hired or if you. already work for the Company. we may order additional background check reports on you for employment purposes without obtaining additional consent, where permitted by law. The consumer reporting agency ("Consumer Reporting Agency-) that will prepare the report is ADP Screening and Selection Services, 301 Remington Street, Fort Collins, Colorado 80 2#. telephone 800-367-5933. In the event that information from the report is utilized in whole or in part in making an adverse decision with regard to your potential employment or earn!) toy meat, before making the adverse decision, we will provide you with a copy of the consumer report and a description in writing of your rights under the law

You have the right to request, in writing, within a reasonable Vine, that we make a complete and accurate disclosure of the nature and scope of the information required. Such disclosure will be made to you within 5 days of the date on which we receive the request from you or within 5 days of die time the report was first requested, whichever is the later. To receive this information or to any files concerning such a report or to determine if a report has been requested, you may convict the Company or the Consumer Reporting Agency.

The Fair Credit Reporting Act and certain state laws give you specific rights in dealing with consumer reporting agencies. You will find these rights in the ahead documents.

Please be advised that we may also obtain an investigative consumer report including information as to your character. General reputation, personal characteristics, and mode of living. By your signature below, you hereby authorize us to order consumer and/or investigative consumer reports including, bus not limited to, the following information: social security number validation criminal, public, educational and, as appropriate, driving records; employment history and earnings history military service credit reports, licensing and certification checks and drug Counseling results. The information may be obtained from private and public repositories of information, and can be disclosed to the processing agency below and its agents

I agree that a facsimile or photocopy of this form is valid Just like the original form.


This report will be processed by:

ADP Screening and Selection Services 301 Remington Street
Fort Collins, Colorado 80524
800-367-5933

   

Applicant's Name:

   

Applicant's Address:

        

City:

        
State:
        
Zip:
        

Signature:

        

Social Security Number:

        

For identification Purposes Only: Date of Birth:

        
Candidate Release Authorization
   

 













  

I. In connection with my application tar employment or continued employment at
   

(the company), I understand that a consumer report and/or an investigative consumer report will be ordered that may include information as to my character, general reputation , personal else act mode on lying, work habits. Performance , and experience. along with reasons for termination employment . I understand that in compliance with applicable law and as directed by company policy and consistent with the job described, you May be requesting information from public and private sources about, not-limited to, my workers' compensation injuries, driving record, court record, education. credentials credit, and references. If company policy requires, I am willing to submit drug testing to detect the use of illegal drugs prior to and during employment.

II. Medical and workers' compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a Consumer Reporting Agency .If so, I will be notified and given the name and address of the agency or the source that provided the information.

III. I acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as valid as the original. This release is valid for most federal state and county agencies including the Minnesota .Department of Labor.

IV. Massachusetts, Minnesota , Oklahoma , New York , Maine , Washington , New Jersey and California applicants only if you want a free of the reports(s) ordered, check this box

V. I hereby authorize, without reservation, any law enforcement, agency institution, information service bureau, school, employer, reference or dim service bureau, school, employer, reference or insurance company Contacted by

VI. I hereby authorize release of information from my Department of Transportation regulated drug and alcohol test testing records by my previous employer to This release is in accordance with DOT Regulation 49 CFR Part 40, Section 40.25. I understand that information to be released by my previous employer, is limited to the following DOT –regulated items alcohol tests with a result of 0.04 or higher verified positive drug tests, refusals to be tested. other violations of DOT agency drug and alcohol testing regulations, information obtained by previous employers of a drug and alcohol rule violation and any documentation of completion of the return –to - duty process following a rule violation.

The following information is required by law enforcement agencies and other entities for positive identification purposes when chocking public records It is confidential and will not be used for any other purposes. I hereby release the employer and agents and all persons, Agencies, and entities providing information of 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.

   
Please print your Full Name :
   
Please print other Names you have used:
        
Current Address:
        
City:
        
State:
        
Zip:
        
Social Security Number:
        
Date of Birth:
        
The following states requite sex and race to obtain information: AL, AR, FL, GA, IA, IL, IN. MI, OR, SC, TX,WI    
Sex:
   
Race:
   
Driver License Number:
        
State Issuing License:
        
 
Name as it appears on license :
        
     
         
         
 
 
Subscribed and Sworn before me
       
Name :
  
Date :
  
Notary Public Signature :
  
My Commission Expires :