Disclosure Regarding Background Investigation

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

Kidney Companions may obtain information about you from a consumer reporting agency for employment and/or volunteer purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living, which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information regarding your credit history, civil records, criminal history records from any criminal justice agency in any or all federal, state, county and local jurisdictions, birth records, social security verification, motor vehicle records (“driving records”), verification of your education or employment history including current position, worker’s compensation injuries, or any other public record or background checks. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report conducted by the consumer reporting agency. The scope of this notice and authorization is allowing the Company to obtain from any outside organization all manners of consumer reports and investigative consumer reports now and throughout the course of your employment and/or volunteer status to the extent permitted by law.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Company at any time after receipt of this authorization and throughout my employment, if applicable. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

I authorize any individual, company, firm, corporation, organization, or public agency to divulge any and all information, verbal or written, pertaining to me, to Kidney Companions or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.

This information obtained will be used for background screening purposes only and will not be used for any other purpose.

Please provide us with the following information so that we may conduct the background investigation.

Name*

First NameMiddle NameLast Name

Maiden Name/All Other Aliases*

Date of Birth*

Date

Social Security Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Driver’s License Number*

State of Issue*

Signature*

Date*

Date