CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK

IN COMPLIANCE WITH THE FCRA and the DPPA

Drivers Lic #____________________________

State Issued______

________________________

____________________________

________

Last Name

First Name

Middle Initial

_________________________________________________________________________
Maiden and/or Other Last Names Used

________________________

_________________________

Current Address

City and County

______________________

______________________

Date of Birth

Social Security Number

________________
State and Zip Code
Circle One:
Male / Female

This authorization and consent for release of personal information acknowledges that
(COMPANY NAME HERE) (Hereafter referred to as "Company") and/or its agent, Secure Search, may now, or at any time I am assigned to, volunteer with or am
employed by this Company, conduct investigations whether the records are of a public, private or confidential nature. These investigations might include, but are
not limited to, searches of educational institutions attended; financial or credit institutions, including records of loans; records of commercial or retail credit agencies;
other financial statements; records of previous employment, including work history, efficiency ratings, complaints and grievances filed by or against me; records
and recollections of attorney-at-law or of other counsel, whether representing me or any other person (in either a civil or criminal case in which I have been
involved); records from the U.S. Veterans' Administration; criminal history information of file in local, state or federal agencies; and motor vehicle records, and
following an employment offer, workers' compensation reports from either the Department of Labor, National Personnel Records or the Industrial Commission or
similar agencies under the provisions of the Fair Credit Reporting Act 15, USC section 1681 et seq. I also authorize the National Personnel Records Center, or
other custodian of my military service record, to release to Secure search, the following information and/or copies of documents from my military service record:
DD214, service record, and any disciplinary records.
I understand that these searches will be used to determine work assignment or employment eligibility under the company's employment or volunteer policies.
Therefore, I authorize and consent for full release of records (either orally or in writing) to the authorized representatives of the company. In addition, I release and
discharge the company and its agent and associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs expenses or any other
charge or complaint filed with any agency arising from retrieving and reporting this information. I understand that according to the Federal Fair Credit Reporting Act,
I am entitled to know whether employment was denied based upon the information obtained and to receive, upon written request, a disclosure of the background
report. I also understand that I may request a copy of the report from my employer who has contracted with Net Detective 1329 S. Woodland Blvd, DeLand, FL
32720 at telephone number (800) 853-9773. After reading this document, I fully understand its contents and authorize the background verification.
Are you applying for employment in California, Minnesota or Oklahoma? Yes ___ No___
If so, do you want a copy of any Consumer Report prepared concerning you? Yes ___ No ___
I understand that California law required Company to give me a copy of any report requested within seven (7) days of the date the information was obtained and
that failure to do so will expose Company to liability (Section 1786.29).

The following are my responses to questions about my criminal record history (if any) with descriptions to any question with a YES answer:
1. Have you ever been convicted or plead guilty before a court of any federal, state, or municipal criminal offense? (Excluding minor traffic violations)
YES
NO
If YES, please provide an explanation below:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
2. Have you ever received deferred adjudication or similar disposition for any federal, state or municipal criminal offense? YES NO
If YES, Please provide an explanation below:
________________________________________________________________________________________________________
________________________________________________________________________________________________________

________________________________________________________________________________________________________
3. Have you ever received probation or community supervision for any federal, state or municipal criminal offense? YES NO
If YES, Please provide an explanation below:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
4. Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States? YES NO
If YES, Please provide an explanation below:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
5. As of the date of this authorization, do you have any pending criminal charges against you? YES
NO
If YES, Please provide an explanation below:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

THIS SECTION IS TO BE USED TO LIST ALL COUNTIES AND STATES OF RESIDENCE SINCE AGE 18 OR HIGH SCHOOL GRADUATION. YOU MUST BE
SPECIFIC ABOUT DATES OF RESIDENCE.
CITY/TOWN

COUNTY

STATE

DATES FROM

TO

I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS AUTHORIZATION IS TRUE, CORRECT AND COMPLETE. I UNDERSTAND THAT IF
ANY INFORMATION PROVES TO BE INCORRECT OR INCOMPLETE THAT GROUNDS FOR THE CANCELING OF ANY AND ALL OFFERS OF
EMPLOYMENT OR VOLUNTEER POSITIONS WILL EXIST AND MAY BE USED AT THE DISCRETION OF THE EMPLOYER.
Signed this _________________ day of _________________________________, 20_____
Applicant (Print Name) _________________________________________________________________________
Applicant Signature __________________________________________________________________________