FAIR CREDIT REPORTING ACT DISCLOSURE

In conjunction with my application for employment (including contract services) with you, my prospective employer, I understand that you intend to hire PeopleCheck Inc/PeopleCheckus.com to obtain Consumer Reports and / or Investigative Consumer Reports (hereinafter called "Reports") about me as defined in the Fair Credit Reporting Act (FCRA) 15 U.S.C. § 1681 et seq. These "Reports" may include information concerning my credit worthiness, credit standing, credit capacity, character, academic background, credentials, work habits, work performance, work experience, reasons for work termination, general reputation, personal characteristics or mode of living. You also may seek information concerning my employment history, workers' compensation history, motor vehicle record, education verification, civil litigation history and/or criminal record. I understand that you will not seek medical or genetic information.

I understand that you may rely on any or all of the above referenced information in determining whether to extend an offer of employment to me. If you contemplate making an adverse employment-related decision that will affect me based, in whole or in part, upon a "Report" obtained from PeopleCheck Inc/ PeopleCheckus.com. I will be provided with a copy of the "Report" and a written summary of my Consumer Rights under the FCRA before you finalize that decision. If an adverse employment decision is ultimately made, I have the right to dispute the accuracy or completeness of the Report and to receive an additional free copy of the Report from PeopleCheck Inc / PeopleCheckus within sixty (60) days for the adverse decision.

I have read the above disclosure and I hereby authorize you, PeopleCheck Inc/PeopleCheckus.com or its authorized agents to obtain the above referenced information about me. I also authorize all agencies, bureaus, employers, information service organizations and individuals to provide any of the above referenced knowledge or information they have concerning me. If I am hired, this authorization shall remain on file and shall serve as an ongoing authorization for you to obtain "Reports" about me from PeopleCheck Inc/PeopleCheckus.com at any time during my employment with you. A photocopy or facsimile of this authorization shall be as valid as the original. I agree that any and all disputes arising from this "Report" shall be brought only in state or federal court in the State of Georgia and shall be governed by, and construed in accordance with, the laws of the State of Georgia.

Notice to California Residents:

Under section 1786.22 of the California Civil Code, you may view the file maintained on you by PeopleCheck Inc./PeopleCheckus.com during normal business hours and on reasonable notice. You may also obtain a copy of this file, either in person or by certified mail, by submitting proper identification and paying the costs of duplication services. You may also receive a summary of the file by telephone by being able to provide adequate identification as to allow PeopleCheck Inc./PeopleCheckus.com to determine with reasonable certainty that you are the subject of the report. PeopleCheck inc./PeopleCheckus.com is required to have personnel available to explain your file to you and must provide an explanation in writing to you any coded information appearing in your file. If you appear in person, another person of your choice may accompany you, providing that this additional person furnishes proper identification. PeopleCheck Inc./PeopleCheckus.com Privacy Policy can be viewed at www.peoplecheckus.com

THIS FORM IS FOR PERMANENT RETENTION IN PERSONNEL FILE.

In conjunction with my application for employment (including contract services) with you, my prospective employer, I understand that you intend to hire PeopleCheck Inc./PeopleCheckus.com to obtain Consumer Reports and / or Investigative Consumer Reports (hereinafter called "Reports") about me as defined in the Fair Credit Reporting Act (FCRA). These "Reports" may include information concerning my character, academic background, credentials, Employment verification, city, county, state or federal court agency or department. You also may/will seek information concerning my employment history, workers' compensation (where available) history, motor vehicle record, education verification, civil litigation history and/or criminal record, Georgia criminal history. Further, I hereby give consent to PeopleCheck to conduct and inquiry and receive any Georgia criminal history record information pertaining to me, which may be contained in the files of any state or local criminal justice agency in Georgia.

I hereby authorize any corporation; employer; former employer; educational institution; private information bureau; law enforcement agency, city county, state or federal court, agency or department and any person that has any record or knowledge of my court, criminal, driving, education, immigration, legal, medical, Social Security Administration to provide any information or records in its possession regarding my history to PeopleCheck, Inc and/or its authorized agents.

I understand that you may rely on any or all of the above referenced information in determining whether to extend an offer of employment to me. If you contemplate making an adverse employment-related decision that will affect me based, in whole or in part, upon a "Report" obtained from PeopleCheck Inc/ PeopleCheckus.com. I will be provided with a copy of the "Report" and a written summary of my Consumer Rights under the FCRA before you finalize that decision. If an adverse employment decision is ultimately made, I have the right to dispute the accuracy or completeness of the Report and to receive an additional free copy of the Report from PeopleCheck Inc / PeopleCheckus within sixty (60) days for the adverse decision.

I have read the above disclosure and I hereby authorize you, PeopleCheck inc./PeopleCheckus.com or its authorized agents to obtain the above referenced information about me. I also authorize all agencies, bureaus, employers, information service organizations and individuals to provide any of the above referenced knowledge or information they have concerning me. If am hired, this authorization shall remain on file and shall serve as an ongoing authorization for you to obtain Criminal, Georgia Criminal "Reports" about me from PeopleCheck Inc./PeopleCheckus.com at any time during my employment with you. A photocopy or facsimile of this authorization shall be as valid as the original. I agree that all disputes arising from this "Report" shall be brought only in state or federal court in the State of Georgia and shall be governed by, and construed in accordance with, the laws of the State of Georgia.

THE FOLLOWING INFORMATION IS REQUIRED TO CONDUCT THE BACKGROUND INVESTIGATION

LIST STATES OF RESIDENCE, OTHER THAN ABOVE, FOR THE PAST SEVEN (7) YEARS:

Notice to California Residents:

Under section 1786.22 of the California Civil Code, you may view the file maintained on you by PeopleCheck Inc. PeopleCheckus.com during normal business hours. You may also obtain a copy of this file. either in person or by mail, by submitting proper identification and paying the costs of duplication services. You may also receive a summary of the file by telephone by being able to provide adequate identification as to allow PeopleCheck Inc./PeopleCheckus/ com to determine with reasonable certainty that you are the subject of the report. PeopleCheck inc./PeopleCheckus.com is required to have personnel available to explain your file to you and must explain to you any coded information appearing in your file. If you appear in person another person of your choice may accompany you, providing that this additional person furnishes proper identification PeopleCheck Inc./ PeopleCheckus.com Privacv Policy can be viewed at www.peoplecheckus.com.

This Form Provided By PeopleCheck Inc.

Fax: 770-535-6780 or 866-755-0840

PeopleCheck - Single Screening Service