Background Checks Authorization

Name*

First NameLast Name

Date:*

I hereby grant Rosenblatt Securities permission to conduct any and all background checks deemed necessary including review of previous U-4 and U-5 submissions, and any prior disciplinary history, for the purpose of extending an offer of employment.

The following questions are required disclosure by our Regulator FINRA.

I further declare that I have: (check Yes for Never)*

	Yes	No
Never been arrested, or had a warrant issued for my arrest.
Never been the subject of a criminal investigation.
Never declared personal bankruptcy.
Never had any civil litigation or judgement(s) against me.
Never had any liens placed upon me or my property.

If you answered No to any of the above, please discuss with your interviewer, and provide detailed documentation, for required FINRA disclosure.

My Social Security number is:*

My Date of Birth (MM/DD only) is:*

Signature*

I instruct and authorize Rosenblatt Securities (the "Company") to obtain a consumer report(s) (or background check report(s)) on me, including any investigative consumer reports and any consumer credit reports.* I also agree that a copy of this form is valid like the signed original.

The consumer reporting agency DISA Global Solutions Inc will conduct the background check and prepare the background check report for the Company. DISA Global Solutions is located at 10900 Corporate Centre Drive, Suite 250, Houston, TX 77041 and can be reached by phone at 877-827-4631, or at www.disa.com.

I understand that, as allowed by applicable law, the Company may rely on this authorization to order additional background check reports, including investigative consumer reports and any consumer credit reports* (1) during my employment or time as a volunteer or independent contractor, as applicable, and (2) from any CRA other than DISA Global Solutions without asking me for my authorization again. I understand the Company may order background check report(s) under my legal name and any other names I may have used.

I also instruct and authorize the following persons, agencies, and entities to disclose to DISA and its agents all information about or concerning me, as allowed by law, including but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. As allowed by law, such disclosures may contain the following information pertaining to me: credit history*; public records; a Social Security number verification; driving records; military service; credentials/certifications; worker's compensation injuries; and verification of prior employment and education.

*I understand that I am instructing and authorizing the Company to obtain a consumer credit report only to the extent permitted by law. If I reside or anticipate being employed in New York City, I understand that I am not being asked to authorize a consumer credit report by signing this document.

By signing below, I understand that I am agreeing to the terms contained in this document.

If you live or work for the Company in California, Minnesota or Oklahoma: Check this box if you would like a free copy of your background check report:

Please print your full legal name:*

First NameMiddle NameLast Name

Signature*

Today's Date*

Date

The information requested below is collected solely for the purpose of aiding the Consumer Reporting Agency (CRA) in completing a background check on you.

Name*

First NameMiddle NameLast NameSuffix

Email*

example@example.com

Date of Birth*

Date

Driver's License Number*

State Issuing License*

Social Security Number*

Enter Nickname(s) Used:

Enter Any Other Names Used (including maiden names):

First NameMiddle NameLast Name

Enter Any Other Names Used (including maiden names):

First NameMiddle NameLast Name

Enter Any Other Names Used (including maiden names):

First NameMiddle NameLast Name

Present Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Addresses Within The Past Seven Years

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Addresses Within The Past Seven Years

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Addresses Within The Past Seven Years

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

FINRA Background Checks Authorization

Credit and Bankruptcy Checks Authorization