Background Authorization Form

I. I understand that an investigative report may be generated on me that may include information as to my character, general reputation, personal characteristics, or mode of living; work habits, performance or experience, along with reasons for termination of past employment/professional license or credentials; financial/credit history; or criminal/civil/driving record history. I understand that US Search or its authorized agents may be requesting information from public and private sources about any of the information noted earlier in this paragraph in connection with Christian Ladies Cleaning Service, LLC’s consideration of me for employment, promotion or position re-assignment or contract now, or at any time during my tenure with Christian Ladies Cleaning Service, LLC, and give my full consent for this information to be obtained.

II. I acknowledge that a telephonic facsimile (FAX) or photographic copy of this release shall be as valid as the original. This release is valid for most federal, state and county agencies.

III. I understand that if I am a resident of Minnesota or Oklahoma (only) I may obtain a copy of the report ordered, and now indicate my desire to do so by checking this box *.

IV. I hereby authorize, without reservation, any financial institution, law enforcement agency, information service bureau, school, employer or insurance company contacted by Christian Ladies Cleaning Service, LLC or our authorized agents, to furnish the information described in Section I.

I. I understand that an investigative report may be generated on me that may include information as to my character, general reputation, personal characteristics, or mode of living; work habits, performance or experience, along with reasons for termination of past employment/professional license or credentials; financial/credit history; or criminal/civil/driving record history. I understand that US Search or its authorized agents may be requesting information from public and private sources about any of the information noted earlier in this paragraph in connection with Christian Ladies Cleaning Service, LLC’s consideration of me for employment, promotion or position re-assignment or contract now, or at any time during my tenure with Christian Ladies Cleaning Service, LLC, and give my full consent for this information to be obtained.

II. I acknowledge that a telephonic facsimile (FAX) or photographic copy of this release shall be as valid as the original. This release is valid for most federal, state and county agencies.

III. I understand that if I am a resident of Minnesota or Oklahoma (only) I may obtain a copy of the report ordered, and now indicate my desire to do so by checking this box *.

IV. I hereby authorize, without reservation, any financial institution, law enforcement agency, information service bureau, school, employer or insurance company contacted by Christian Ladies Cleaning Service, LLC or our authorized agents, to furnish the information described in Section I.

Full Name*

First NameMiddle NameLast Name

Other Names Used, if Any:

Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Previous Address 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Previous Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes.

Social Security Number:*

Date of Birth*

Driver's License #:

State of Issue:

Name as it Appears on License:

Have you ever been convicted of a crime?*

If yes, please provide city and state of conviction and details of conviction.

List any relevant skills

Signature*

Today's Date*

By clicking the submit button below, I cerity that all of the information provided by me on this questionnaire is true and complete, including my signature above, and I understand that if any false information, ommissions, or misrepresentations are discovered, my application may be rejected.

FAIR CREDIT REPORTING ACT NOTICE:

In accordance with the Fair Credit Reporting Act (FCRA, Public Law 91-508, Title VI), this information may only be used to verify a statement(s) made by an individual in connection with legitimate business needs. The depth of information available varies from state to state. Status of updates are available on request. Although every effort has been made to assure accuracy, DirectScreening.com cannot act as guarantor of information accuracy or completeness. Final verification of an individual’s identity and proper use of report contents are the user's responsibility. Our authorized agent, DirectScreening.com, has a policy that requires purchasers of these reports to have signed a Service Agreement. This assures DirectScreening.com that users are familiar with and will abide by their obligations, as stated in the FCRA, to the individuals named in these reports. If information contained in this report is responsible for the suspension or termination of an employee or the application process, have the candidate/employee contact DirectScreening.com at 190 Haverhill Street, Methuen, MA 01844.

NOTICE TO CALIFORNIA CANDIDATES

You have a right to obtain a copy of any consumer report or investigative consumer report obtained by Christian Ladies Cleaning LLC by checking the box provided below. The report will be provided to you within (3) business days after we receive the requested reports related to the matter investigated.

Under section 1786.22 of the California Civil Code, you may view the file maintained on you by DirectScreening.com during normal business hours. You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services, by appearing at DirectScreening.com in person or by mail. You may also receive a summary of the file by telephone. The agency is required to have personnel available to explain your file to you and the agency must explain to you any coded information appearing in your file. If you appear in person, a person of your choice may accompany you, provided that this person furnishes proper identification.

I request to receive a free copy of this report by checking this box.

Copy Requested

Pre-Employment Inquiry Authorization Release

Sign & Send: