I certify and declare under penalty of perjury under relevant state and federal law that the information contained in my employment application is complete, true and accurate. I acknowledge that falsification or omission of information may result in immediate dismissal or retraction of any offer of employment.

In consideration of ___________________________________________________'s review of my application for employment, (herein referred to as EMPLOYER) I hereby voluntarily consent to and authorize EMPLOYER, or its authorized agents bearing this release or copy thereof, to obtain a consumer report for employment purposes. I agree that this consumer report may include any of the following:

• Employment Verification , Education Verification , Credentials Verification , Military Service Verification
• Personal Identity Verifications , Past Employment Verification , Reference Checks
• Criminal Records , Civil Cases , Motor Vehicle Records , Credit Report

I authorize all persons and organizations that may have information relevant to this research to disclose such information to EMPLOYER or its authorized agents. I hereby release EMPLOYER, its authorized agents, and all persons and organizations providing information from all claims and liabilities of any nature in connection with this research. I hereby further authorize that a photocopy of this authorization may be considered as valid as the original.

I understand that I have specific prescribed rights as a consumer under the federal Fair Credit Reporting Act ('FCRA'), and may have additional rights under relevant state law. I hereby certify that I have been presented with a summary of my rights as a consumer under the Fair Credit Reporting Act.

_____________________________________________	_________
Signature of Applicant	Date

______________________________________________
Printed Name

____________________________________Date of birth

____________________________________Social Security number

____________________________________Drivers license number # and State of issue