Comcast/Madison Background

Contractor Badge Holder Data Information Sheet

Madison
Please Do Not leave ANY blanks!
Name*

First NameLast Name
Address*

Address

Street Address Line 2

CityState/Zip

Postal / Zip Code
Gender*
Race*
Hair Color*
Eye Color*
Glasses*
Y/N
Height*
Weight*
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Drivers License #*
DL State*
Exp Date*

MonthDayYear
Date
Cell Phone Number*
Last 4 Social Sec #*
Please note if you will be using a company vehicle, go ahead and list your personal vehicle information and you can update it once your company vehicle has been assigned. You will not be badged if this form is not filled out completely.
Vehicle Use (personal or company)*
Make*
Model*
Color*
Year*
License Plate #*
Plate State*
Do you have cable Experience?*
Y/N
If yes, how many years experience?
Expected Training Start Date*

MonthDayYear
Date
Expected Area of work after training: (Dallas, Atlanta, Cobb, etc)*
By Signing, I guarantee that all information provided is true and correct to the best of my knowledge.
Badgeholder's signature*

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Disclosure: We (MADISON TELECOMMUNICATIONS) will obtain one or more consumer reports or investigative con- sumer reports (or both) about you for employment purposes. These purposes may include hiring, contract, as- signment, promotion, re-assignment, and termination. The reports will include information about your character, general reputation, personal characteristics, and mode of living. We will obtain these reports through a consumer reporting agency. Our consumer reporting agency is backgroundchecks.com ("BGC" BGC's address is P.O. Box 353, Chapin, SC 29036. BGC's telephone number is (866)265-6602. To prepare the reports, BGC may investigate your education, work history, professional licenses and credentials, references, criminal record, lawsuits, driving record, credit history, and any other records with public or private information sources. You may inspect BGC's files about you (in person, by mail, or by phone) by providing identification to BGC. If you do, BGC will provide you help to understand the files, including trained personnel and an explanation of any codes. Another person may accompany you by providing identification. If BGC obtains any information by interview, you have the right to ob- tain a complete and accurate disclosure of the scope and nature of the investigation performed. The Federal Trade Commission provides a summary statement of your rights on its website at http://www.ftc.gov/credit.

Personal Information: Please print the information requested below to identify yourself for our agency.
First*
Middle*
Last*
Maiden
Other names used
Street Address*
City, State & Zip*
from Mo/Yr*
to Mo/Yr*
Current
Street
City, State & Zip
from Mo/Yr
to Mo/Yr
Some government agencies and other information sources require the following information when checking for records. Our agency will not use it for any other purposes.
Date of birth*

MonthDayYear
Date
Social security number*
Driver's license number & state*
Name as it appears on license*
Report Copy: If you are applying for a job or live in California, Minnesota, or Oklahoma, you may request a copy of the report by checking this box:
Authorization: vate information By signing below, you authorize: (a) BGC to request information about you from any public pri- source; (b) anyone to provide information about you to BGC; (c) BGC to provide us one or reports report related based on that information; and (d) us to share those reports with others for legitimate business or more Your purposes Rights under to your employment. You acknowledge receiving the Federal Trade Commission's is as valid the Fair Credit Reporting Act." You acknowledge that a fax, image, or copy of this "Summary of with us. as the original. You make this authorization to be valid for as long as you are an applicant or authorization employee
Signature*

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Date*

MonthDayYear
Date
GEORGIA BUREAU OF INVESTIGATION GEORGIA CRIME INFORMATION CENTER

In signing below, I hereby authorize the agency in possession of this document to release any and all Georgia criminal record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia.

I understand that backgroundchecks.com/GBRS is requesting this information on behalf of Madison Telecommunications Inc and give my full consent for periodic criminal history background checks to be performed for the duration of my employment with this company.
Full Name (print: Last, First, and Middle Name)*
Alias/Maiden names
Address*
City*
State*
Zip Code*
Month, Day and Year of Birth*
Social Security Number*
Signature*

Clear
Date*

MonthDayYear
Date
Comcast is required to certify to the FCC that it complies with Customer Proprietary Network Information (CPNI) regulations. CPNI rules limit the circumstances under which employees and contractors can sell additional services to customers of Comcast Digital Voice and Comcast Digital Phone service. In addition, the CPNI rules prohibit disclosure of any protected information, so you may only discuss details of the customer's voice service account with the customer or someone designated by the customer. Since you may have access to CPNI during the course of your interaction with customers, you are required to complete training on CPNI. This requirement will be fulfilled when you familiarize yourself with this memo, sign the attached certification form and send it to your appropriate Comcast management contact. Please do so within five business days of receiving this memo, Failure to complete the training can result in disciplinary measures up to and including termination of employment with Comcast.

CPNI is information regarding an individual customer's voice service, such as how many voice lines a customer has, how the service is arranged or provisioned, and information about to whom, where, how long and how often calls are made by a customer. Billing information and most information about a customer's CDV service is also CPNI. The customer's name, address and phone number are not CPNI. All traditional telephone as well as interconnected VOIP service providers are required by the FCC to keep CPNI secure from unauthorized users. Comcast employees, vendors and contractors must not discuss or disclosure any customer's CPNI with unauthorized persons. Doing so will result disciplinary action up to and including termination of employment with Comcast.

In addition, the FCC puts limits on how CPNI can be used to sell voice customers additional services. CPNI can only be used with a customer' permission to sell services that are not part of a category the customer already purchases. For example, you may not use CPNI to market video tiers to a customer without the customer's approval. You may use CPNI to talk to the customer about services such as speed dialing, call waiting, caller ID, call forwarding, inside wiring installation, maintenance and repair, and High-Speed Internet Services. Customer permission can be checked by reviewing Comcast's records for each customer. Customers can also give one- time approval to use CPNI.

For example if a Customer Account Executive or Care Representative (CAE) is speaking to a CDV customer regarding his yoice service and would like to view the customer's call detail record in order to see if the customer calls Mexico and would possibly be interested in subscribing to the latino video tier, the CAE MUST ask the customer for permission to view his

call detail record and explain the purpose for doing so. If the customer provides his permission the CAE MUST document that they have received permission and may continue. If the customer does not provide permission the CAE may not view the customer's CPNI.

If you mistakenly use CPNI information when speaking with or about a customer, or if you become aware of non-approved use of CPNI, report it to your supervisor immediately.

CERTIFICATION FORM MUST BE SIGNED AND SUBMITTED TO THE APPROPRIATE COMCAST MANAGEMENT CONTACT WITHIN FIVE BUSINESS DAYS.

COMCAST CONFIDENTIAL & PROPRIETARY
I hereby cerify that I _________________________ have completed Comcasts annual CPNI training.
Name*
Signature*

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Date*

MonthDayYear
Date
COMCAST CONFIDENTIAL & PROPRIETARY
Should be Empty:

Contractor Badge Holder Data Information Sheet

By Signing, I guarantee that all information provided is true and correct to the best of my knowledge.

Report Copy: If you are applying for a job or live in California, Minnesota, or Oklahoma, you may request a copy of the report by checking this box: