IntelliCorp Authorization STAND ALONE VERS DISCLOSURE FOR INVESTIGATIVE CONSUMER REPORTPlease Read Carefully Before Signing the Authorization DISCLOSURE ALLSTAFF (“The Company”) may request an investigative consumer report about you from a third party consumer reporting agency for employment (including independent contractor or volunteer assignments, as applicable). An “investigative consumer report” is a background report that includes information from personal interviews (except in California, where that term includes background reports with or without information obtained from personal interviews). The most common form of an investigative consumer report in connection with your employment is a reference check through personal interviews with sources such as your former employers and associates, and other information sources. The investigative consumer report may contain information concerning your character, general reputation, personal characteristics, or mode of living. You may request more information about the nature and scope of an investigative consumer report, if any, by contacting the Company. You have the right, upon written request made within a reasonable time, to request (1) whether an investigative consumer report has been obtained about you, (2) disclosure of the nature and scope of any investigative consumer report and (3) a copy of your report. These reports will be conducted by IntelliCorp Records, 3000 Auburn Drive, Suite 410, Beachwood, Ohio 44122; Tel. No. 1.888.946.8355; www.intellicorp.net. The scope of this disclosure is all-encompassing, however, allowing the Company to obtain from any outside organization all manner of investigative consumer reports to the extent permitted by law. ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK I have certify I have read the foregoing Disclosure and understand it and this authorization. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by ALLSTAFF” at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by IntelliCorp, 3000 Auburn Drive, Suite 410, Beachwood, Ohio 44122; Tel. No. 1.888.946.8355; www.intellicorp.net. Please Select One: CONSENT FOR AUTHORIZATION * I DO I DO NOT authorize you to contact, through lntelliCorp Records, Inc., my current employer for Employment and Reference Verifications. (Checking "I do" will authorize inquiries to the Human Resources Department and to any listed supervisors.) I also consent to have any legally required notices sent electronically. Personal Data First Name Last Name Middle Name Current Address Current Address Current Address Current Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Lived There Since (date) Date of Birth Other Names Used (including maiden name) Years Used Social Security Number Driver's License # DL State Email address (may be used for official correspondence) SIGNATURES Signature signature keyboard Clear Date Parent or Legal Guardian Signature (if under age 18) signature keyboard Clear (for searches conducted on minors under the age of 18). Date If you are human, leave this field blank. Submit