Applicant Authorization for Release of Information

I  __________________________________________________________________________

Under the provisions of the Fair Credit Reporting Act, 15 USC, Section 1681 et seq.,  the Americans with Disabilities Act and all applicable federal, state and local laws,  understand that in conjunction with my application  for employment, work preformed under contract, promotion, reassignment, and/or retention (“Employment”), that

Company Name:________________________________________________________________________

(Hereafter referred to as “Company”) will contact and enlist the services of LB Safety Operations Services, Inc., as part of my employment and/or continued employment.  I understand  that a consumer report and/or an investigative consumer report will be obtained. That various sources and information will be used and may include but not limited to the following: Personal and professional references, current and former employers, education, military records, credit bureaus, municipal, county, state and federal agencies and courts, agencies that provide motor vehicle records, business licenses, workers compensation, drug and alcohol testing, and/or other information deemed necessary to fulfill the job requirements. The results of this information will be used to determine employment eligibility or advancement under the “Company” employment policies. I agree, authorize and consent to the release and disclosure of any and all information, including but not limited to the above “Company” and LB Safety Operations Services, Inc.

I agree that a copy of this authorization has the same effect as an original.

I herby release and hold harmless any person, firm, or entity that discloses matters in accordance with this authorization, as well as from liability that might otherwise result from the request for use of and/or disclosure of any and all of the foregoing information.

I understand and acknowledge that under the provision of the Fair Credit Reporting Act I may request a copy of any consumer report from the consumer reporting agency that compiled the report.

This authorization shall remain in effect over the course of my employment. Reports may be ordered periodically during the course of my employment. NOTE: Except for those states where an annual release is required, i.e. California.

Full Name ____________________________________________________

Address______________________________________________________

DOB ___________     Drivers License______________________  STATE_____

Social security # ________________________________________________

Signature______________________________________ Date____________

Employer's Signature_______________________________   Date___________