The Harvest Disclosure & Release of Liability Form

The Harvest Disclosure & Release of Liability Form
To: The Core Group Fax Number: (713)880-9595

From: The Harvest

By my signature below, I authorize The Harvest to obtain information - written, oral, or other - from a courthouse records research firm bearing on my character general reputation, personal characteristics, mode of living, criminal background and driving record. I understand that this investigation may include interviews with friends, acquaintances, or others.

The information I have given is correct and you may verify the information listed if necessary. I understand that I am a volunteer at will and that The Harvest reserves the right to disqualify me from my volunteer position for any reason it deems appropriate. I hereby release and hold The Harvest harmless from all claims arising under this application.
Section 2, Release of Liability

I agree that any inaccurate or incomplete records or information provided to The Cole Group will be the sole responsibility of the appropriate government source. Accordingly, I hereby release from liability and hold harmless the Cole Group, and The Harvest, and all of the owners, officers, and employees of both companies from any blame, claim, lawsuit, liability, compensation, or damages arising out of or relating to the acquistion or use of this information. I consent to and request that The Cole Group communicate to The Harvest, all information obtained now and in the future from the above sources.
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Name*

First NameLast Name
Date*

MonthDayYear
Date
PLEASE VERIFY ALL OF THE BELOW INFORMATION FOR ACCURACY
First Name First Name* Middle Name Last Name*
List other last names used specific years they were used (Maiden Name, Other Married Names, Etc.)
Date of Birth*
Social Security Number*
Driver's License Number*
State (Driver's License)*
Indicate below prior Cities/States of residence and specific years lived there
CITYcity* STATEblank*
LIVED THERE FROM (YEAR) year* TO PRESENT
CITYcity STATEblank
LIVED THERE FROM (YEAR) year TO
CITYcity STATEblank
LIVED THERE FROM (YEAR) year TO
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The Harvest Disclosure & Release of Liability Form

PLEASE VERIFY ALL OF THE BELOW INFORMATION FOR ACCURACY