BACKGROUND CHECK DISCLOSURE

DISCLOSURE

As part of evaluating your application for employmentand promotion, ______ (“Company”) has a policy of obtaining employment background screening reports on applicants and employees as a condition of initial and continued employment. Company may obtain from Americhek Inc, a national screening firm and consumer reporting agency, consumer reports.All employment screening inquiries are limited to information that affects job performance at the workplace. Background screening is conducted in accordance with applicable Federal and state laws including the Fair Credit Reporting Act (FCRA) the Americans with Disabilities Act (ADA), the Driver Privacy Protection Act, and anti-discrimination and privacy laws. As a result, the Company may obtain a Consumer Report and an Investigative Consumer Report on you initially and during your tenure of employment.

Americhek Inc, 27001 La Paz Road, Ste 278-B, Mission Viejo, CA 92691 Tel: (888) 624-7412 (Fax (888) 667-6620 will obtain the reports for the Company. Reports may contain information bearing on your character, general reputation, personal characteristics, mode of living and credit standing. The types of information that may be obtained include, but are not limited to: social security number verifications, credit reports, criminal convictions and records, civil records, court records, driving records, educational records, employment verification, personal and professional references checks, licensing and certification records, drug testing results, date of birth verification, etc. The information contained in the reports will be obtained from private and public record sources and may include personal interviews.

1. A Consumer Report consists of information deemed to have a bearing on job performance, and may include information from public and private sources, public records, former employers and references. The scope of the report may include information concerning your driving record, civil and criminal court records, credit, education, credentials, identity, past addresses, Social Security number, previous employment, professional references, and your personal references.

2. An Investigative Consumer Report may also include reference checks from former employers, co-workers or references for the purposes of obtaining job related information. This type of report is defined as a report based upon interviews that may contain information relating to your character, general reputation, personal characteristics, or mode of living. You have the right to request additional disclosures of the nature and scope of an investigative consumer report. To receive this information or to inspect any files concerning such a report or to determine whether a report on you has been requested, you may contact: ____________or Americhek Inc, 27001 La Paz Road, Suite 278-B, Mission Viejo, CA92691 Tel:(888) 624-7412 Fax (888) 667-6620.

3.Additional State Law Disclosure Form: If you are living or applying for work inCalifornia,Maine, Massachusetts, New York, or Washington, please read and signappropriate portion of the attached page.

4.California Provisions: In California, any report concerning a consumer's character, general reputation, personal characteristics, or mode of living is defined as an Investigative Consumer Report. In California a separate authorization is required to authorize the running of a credit report.

Disclosure Forms Developed by Net Check Investigations, California PI License 21529

AUTHORIZATION TO RELEASE INFORMATION

AUTHORIZATION

I have carefully read and understand the attached Disclosure,the attached Summary of Rights under the Fair Credit Reporting Act,Additional State Law Disclosure Form(if applicable), andthis Authorization Form. By my signature below, I consent to the release of consumer reports and investigative consumer reports prepared by Americhek Inc, a national consumer reporting agency, to the Company and its designated representatives and agents. I understand that if the Company hires me, my consent will apply, and the Company may obtain reports, throughout my employment. I also understand that information contained in my job application or otherwise disclosed by me before or during my employment, if any, may be used for the purposes of obtaining consumer reports and/or investigative consumer reports.

By signing below, I authorize law enforcement agencies, learning institutions (including public and private schools and universities), information services bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past and present employers, the military, and other individuals and sources to furnish any and all information on me that is requested by the consumer reporting agency.

Further, I certify the information I provide on this form is true and correct. I agree that this Disclosure and Authorization form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for any reports that may be requested by or on behalf of the Company.

California, Minnesota or Oklahoma applicants only– You will be provided with a free copy of any consumer reports or investigative consumer reports obtained on you if you check the box below.
I wish to receive a free copy of the report.

Full Legal Name: ______Today’s Date: ______

Signature: ______Date of Birth: ______

Maiden/other names used: ______SSN: ______

Driver’s License Number: ______State Issued: ______

Current Address: ______City:______

State: ______Zip:______

Prospective Employer: ______

Disclosure Forms Developed by Net Check Investigations, California PI License 21529

ADDITIONAL STATE LAW NOTICES & DISCLOSURE

If you are aCalifornia,Maine, Massachusetts, New York, or Washingtonapplicant or employee, please read the appropriate box to learn more about your additional state rights.

CALIFORNIA: Under section 1786.22 of the California Civil Code, you may view the file maintained on you by Net Check during normal business hours. You may also obtain a copy of the file, upon submitting proper identification and paying the costs of duplication services, by appearing at Net Check’s offices in person, during normal business hours and on reasonable notice, or by mail. You may also receive a summary of the file by telephone, upon submitting proper identification. Net Check has trained personnel available to explain your file to you, including any coded information. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification.
MAINE: You have the right, upon request, to be informed of whether an investigative consumer report was requested, and if one was requested, the name and address of the consumer reporting agency furnishing the report. You may request and receive from the Company, within five business days of our receipt of your request, the name, address and telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly receive from all such agencies copies of any such reports.
MASSACHUSETTS: If you ask, you have the right to a copy of any consumer report concerning you that the Company has ordered. You may contact Americhek Inc. for a copy.
NEW YORK: You have the right, upon request, to be informed of whether or not a consumer report was requested. If a consumer report is requested, you will be provided with the name and address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of the report by contacting that agency. You may contact Net Check for a copy of Article 23-A of the New York Correction Law will outline your additional rights for New York residents.
WASHINGTONSTATE: If we request an investigative consumer report, you have the right, upon written request made within a reasonable period of time after your receipt of this disclosure, to receive from us a complete and accurate disclosure of the nature and scope of the investigation we requested. You also have the right to request from the consumerreporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

Disclosure Forms Developed by Net Check Investigations, California PI License 21529