CONSENT TO BACKGROUND SEARCH AND INVESTIGATION

The undersigned hereby authorizes (name of company) ___________________________________ (hereinafter referred to as "Company") and/or its agents to make an investigation of my background, references, character, past employment, credit reports, education, and criminal history record information which may be in any state or local files, including those maintained by both public and private organizations, and all public records, for the purpose of confirming the information contained in my application and/or obtaining other information which may be material to my qualifications for employment. A telephone facsimile (fax) or xerographic copy of this consent shall be considered as valid as the original consent.
Prior to taking any adverse action as a result of such investigation, Company shall provide to me a copy of the consumer report which caused such adverse action and a summary of my rights under the Fair Credit Reporting Act.
I release Company and/or its agents and any person or entity which provides information pursuant to this authorization from any and all liabilities, claims, or lawsuits in regard to the information obtained from any and all of the above-referenced sources.
The following is my true and complete legal name, and all information is true and correct to the best of my knowledge:

True and Complete
Legal Name: First:_____________________ Middle:_____________________ Last:_____________________
Maiden or Other Names Used:________________________________________ Dates Used:_______________
Present Street Address:____________________________________________ Years of residence: 20__ to 20__
City:___________________________________ County:_______________ State:_____________ Zip:_______
Previous Street Address: __________________________________________ Years of residence: 20__ to 20__
City:__________________________________ County:________________ State:_____________ Zip:_______
Other cities and states lived in during the past seven years:
City:________________________________________ State:_____________ Years of residence: 19__ to 19__
City:________________________________________ State:_____________ Years of residence: 19__ to 19__
City:________________________________________ State:_____________ Years of residence: 19__ to 19__
Driver's License Number:_____________________________________________ State of Issue:_____________
Date of Birth: _____________________ Social Security Number:_____________________________________
Signature:_________________________________________________________ Date:___________________
Note: The above information is required to ensure positive identification and is in no manner used as qualification for employment.

COMPANY REQUEST FOR PROCESSING
[ ] Employment verification
 # of employers to verify: _____
   [ ] Professional reference
 # of references to verify: _____
   [ ] Education Verification
[ ] Criminal History    [ ] Credit History    [ ] Professional License Verification

[ ] Motor Vehicle Record    [ ] Social Security Number Verification
If relevant to request, include job history, reference names and tel numbers, and educational background.
Requestor: ______________________________________
Company Tel No: (____) _____________
Company Fax No: (____) _____________

Fax to MSI Investigations at: 603-298-6080