Reference Check Consent Form

In accordance with the Federal Fair Credit Act (FCRA), I consent to your obtaining information about my experience and background in working with me on career opportunities. The information may include materials, records, and written and verbal reports relating to my prior job experience and performance, education, credit history and rating, driving record, and criminal and civil litigation record, if any. It may also include results of tests and assessments administered by you or others. You may provide this information to prospective employers. You have told me that, under the FCRA, I have the right to request that you disclose to me the "nature and substance" of all information about me in your file. In addition, I release your company and its employees and agents from all liability relating to your obtaining and use of such information and your providing such information to prospective employers. I authorize all companies, schools, organizations and other persons to provide such information to you and release them for all liability for doing so.   ______________________________ Candidate's Signature ______________________________ Candidate's Name (please print) ______________________________ Date ______________________________ Social Security Number ______________________________ Date of Birth Attention: ______________________________

Please fax completed form to: 804-282-4990