NON LICENSED EMPLOYEES

By my signature below, as a new or perspective employee of the above Employer blanks (applicant's name), hereby understand that a thorough investigation of any record of past criminal activities will be conducted from the files of the Louisiana Department of Public Safety and Corrections, Office of the State Police and a security check will be made through the United States Department of Justice's National Sex Offender Public Registry for sexually violent convictions by an authorized law enforcement agency as required by Louisiana's R.S. 40:1300.51 et seq.

Also, Follow up investigations may be made into the available records of courts or other governmental jurisdictions, i. e. local, parish/county, State of Louisiana, other states and/or the Federal government, if necessary, to obtain files to complete an accurate criminal history as required by State or Federal regulatory agencies or Employer. I hereby authorize such an investigation and further give permission to authorized law enforcement agencies and/or courts to release all criminal history and sex offender conviction record information maintained in their files which may confirm or deny my eligibility for employment with the Employer named above to Ernest Freeman III, Authorized Agency. The Authorized Agency will relay this information to the Employer or prospective Employer named above,

Also, It is my understanding that the results of the investigation will remain confidential and that if any inaccurate information is found to exist, I will be provided an opportunity to refute, correct or otherwise clarify such information as outlined in the FCRA guide, "A Summary of Your Rights Under the Fair Credit Reporting Act''

Also, I understand that this consent gives permission for Employer to conduct additional reports during my term of employment. I acknowledge that it is a crime to provide false information to the Employer,

Name*

First NameMiddle NameLast Name

Job Title*

Social Security Number*

Driver's License Number or State ID Number*

State*

Race*

Sex M/F*

Date of Birth*

mm/dd/year

Phone Number*

Current Address*

Street Address

Street Address Line 2

CityState

Zip Code

Previous Address 1

Street Address

City

StateZip Code

Dates (Month / Year)

Previous Address 2

Street Address

City

StateZip Code

Dates (Month / Year)

I hereby agree to indentify and hold Employer and Authorized Agency, their agents, representatives, employees, any law enforcement agency and court contacted by Authorized Agency to conduct the herein authorized investigation of my criminal history and sex offender convictions harmless from any and all damages, of whatever type or nature including court costs and reasonable attorney fees suffered by any person, including the undersigned, as a result of the investigation into my criminal history and sex offender convictions authorized to be conducted herein, I understand and agree that the investigation will be based upon a review of the State of Louisiana's Criminal History Records Database, the United States Department of Justice's National Sex Offender Public Registry, and the databases of law enforcement agencies and court systems identified above; it will not include an investigation into the criminal records of the Federal Bureau of investigation's Identification Division Files.

Applicant's Signature*

Date*

Signature of Administrator or Designated Representative (Witness)

Date

NON LICENSED EMPLOYEES

***INFORMATION BELOW MUST BE CORRECT AND PRINTED CLEARLY***

INFORMATION BELOW MUST BE CORRECT AND PRINTED CLEARLY