I, _________________________, hereby consent and authorize _________________________ or it's agents to prepare an investigative consumer report, including but not limited to obtaining a consumer report and information as to my credit worthiness, credit standing, character, general reputation, credit capacity, personal characteristics, and mode of living. This report may involve personal interviews with sources, such as neighbors, friends, associates, past employers and educational institutions in which case I understand that I am entitled to a copy of my rights under the FCRA as well as to request additional disclosures of the nature and scope of the investigation. Public records may be used in this report, such as civil and criminal records, driving records, liens, judgments, and bankruptcy that are deemed to have a bearing on my job performance. This consumer report will be used for employment purposes as it is defined in the Fair Credit Reporting Act, section 603 (h). In using a consumer report for employment purposes, before taking any adverse action based in whole or in part on the report, the person intending to take such adverse action shall provide to the consumer to whom the report relates, a copy of the report and a description in writing of the rights of the consumer under the FCRA, as prescribed by the Federal Trade Commission, section 609(c)(3).

I am providing the following information for the preparation and proper verification of the consumer report.

All previous names used and corresponding years: ____________________________________

Drivers license number: _____________________________________________________________

State of issuance: ___________________________________________________________________

Date of birth: _______________________________________________________________________

Social Security No: _________________________________________________________________

Current county of residence: _______________________________________________

All past counties of residence and corresponding years: _______________________________

___________________________________ Signature	_____________________________ Date
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