APPLICATION FOR RELEASE OF
EMPLOYMENT RECORDS AND INFORMATION

In connection with my performance of services to _____________ (contracting company),
I _________________________ understand that investigative inquiries are to be made of my consumer credit
history, criminal convictions, workers’ compensation records, motor vehicle driving records, and other reports.
These reports will include but are not necessarily limited to, information as to my character, general
reputation, performance and experience as well as reasons for separation from previous employment. I
understand that Information Network Associates, Inc. (INA) will be requesting information from various
federal, state, local and other agencies that maintain records concerning my past activities relating to civil
litigation, my driving, credit, criminal, education, previous employment and other experiences. I recognize
further that INA may conduct a periodic background investigation during the course of my provision of
professional services to_________ (contracting company), including a consumer credit report. I authorize all
corporations, companies, credit agencies, persons, educational institutions, law enforcement agencies and
former employers to release information they may have about me, and I release them, _________(contracting
company) and INA from any liability and responsibility from doing so; further, I authorize the procurement of
an investigative consumer report and understand that such a report may contain information as to my financial
situation, background, mode of living, character and personal reputation. This authorization, in original and
copy form, shall be valid for this and future reports that may be requested by __________ (contracting
company) during the course of my provision of services to____________ (contracting company).
I authorize, without reservation, any party or agency contacted by INA on behalf of ____________
(contracting company) to furnish the above mentioned information and release INA and ____________
(contracting company) of any and all liability of every kind and nature.
I understand to aid in the proper identification of files or records pertaining to me, the following
personal identifiers are necessary. This information is being sought for the sole purpose of performing a
lawful background check as described above and is voluntarily furnished. I further understand that INA will
comply with the federal Fair Credit Reporting Act (FCRA), Public Law 91-50815
USC§ 16810 et Seq., the Health Insurance Portability and Accountability Act, the Driver’s Privacy Protection
Act (DPPA) and all other relevant federal, state and local laws and regulations now in effect or as
subsequently amended or adopted. It is understood that INA will only release these records to ____________
(contracting company). I __________________________ certify that information contained on this form is
true and correct.