APPLICANT: __________________ __________________ ___________________ . LAST NAME FIRST NAME MIDDLE NAME

COMPANY: ______________________________________.

APPLICANT understands that in conjunction with APPLICANT’S application, COMPANY will use the services of an outside agency to research and verify the information APPLICANT has provided on APPLICANT’s application including APPLICANT’s personal background, character, professional standing, work history and qualifications. This outside agency will perform related background investigations and will subsequently provide a written report of its findings to COMPANY.

APPLICANT understands that the outside agency may utilize various sources of information it deems appropriate to conduct background investigations. APPLICANT hereby authorizes, requests and consents to the release and disclosure of any and all information to COMPANY for the purposes of conducting said background check. APPLICANT further authorizes, requests and consents to the procurement of any Investigative Consumer Report and/or Consumer Credit Report by COMPANY and understands that said reports may contain information about APPLICANT’S background, mode of living, character, personal characteristics and general reputation.

This authorization in original or copy form shall be valid for one year from the date indicated next to the signature of APPLICANT. According to the Fair Credit Reporting Act, APPLICANT will be notified by COMPANY if the application is denied because of information obtained from a Consumer Reporting Agency. Additionally, APPLICANT understands that if requested within 60 days, APPLICANT will be given a full and accurate disclosure as to the nature and substance of all information provided to COMPANY. APPLICANT further understands that when requesting a copy of the report, proper identification will be required. APPLICANT understands that residents of the State of California will automatically receive a copy of the report within 7 days of its delivery to the employer. APPLICANT understands that residents of all other states will automatically receive a copy of the report if an adverse action is taken regarding the application, or upon request as outlined above.

____CHECK HERE if APPLICANT is applying for work with a Minnesota employer and would like a copy of his or her Consumer Report if such a report is included in the investigation of APPLICANT’S background. Minnesota Code 13C Subdivision 2.

APPLICANT HEREBY RELEASES COMPANY AND COMPANY’S REPRESENTATIVES AND AGENTS INLCUDING YOUROWNPRIVATEEYE.COM, A California Corporation, AND ALL PERSONS, AGENCIES, AND ENTITIES PROVIDING INFORMATION OR REPORTS ABOUT APPLICANT FROM ANY AND ALL LIABILITY ARISING OUT OF THE REQUEST FOR OR RELEASE OF ANY OF THE ABOVE-MENTIONED INFORMATION OR REPORTS. APPICANT’S INITIALS: __________.

______________________________ ___________________________
Signature of Applicant Today’s Date

______________________________ ___________________________
Printed Name of Applicant Position Applied For

______-____-______ ____/_____/____ _____________________ _________
Social Security Number Date of Birth Driver’s License # State

Other names you have used or are also known as: __________________________________________________________________________

PLEASE PROVIDE ALL RESIDENTIAL ADDRESSES FOR THE PAST 7 YEARS

Current Address:_________________________________________________________________
Street Apt.# City State Zip

Former Address:_________________________________________________________________
Street Apt.# City State Zip

Former Address:_________________________________________________________________
Street Apt.# City State Zip

Former Address:_________________________________________________________________
Street Apt.# City State Zip

Former Address:_________________________________________________________________
Street Apt.# City State Zip

Former Address:_________________________________________________________________
Street Apt.# City State Zip