Company Name:

In connection with your application and/or employment with above listed Company (hereinafter “the Company”) this notice is provided to inform you that a “consumer report” and/or “investigative consumer report,” as defined by the Fair Credit Reporting Act (15 U.S.C. § 1681), may be obtained from a consumer reporting agency for employment purposes. These reports may include information about your character, general reputation, personal characteristics and mode of living, whichever are applicable. The report may also contain information about you relating to criminal history, credit history, motor vehicle records such as driving records, worker's compensation claims (post job offer or conditional job offer),verification of education or employment history, social media or other background checks. They may involve personal interviews with sources such as your neighbors, friends or associates. 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 to the Company and National Crime Search, LLC, 3452 E. Joyce Blvd., Fayetteville, AR 72703 – 888-527-3282. For information about National Crime Search, LLC’s privacy practices see www.nationalcrimesearch.com. The scope of this notice and authorization is not limited to the present and, if you are hired, will continue and allow the Company to conduct future background screenings for retention, promotion or reassignment, unless revoked by you in writing.* The Company also reserves the right to share your report with any third-party for whom you will be placed to work with as a representative of the Company.

Signature:

Date:

Parent/Guardian Signature**:

Other or Former Names (please print):

Full Legal Name (please print)

City/State

Address :

Date of Birth

SSN

County

Zip

Driver’s License#

State issued

Name on Driver’s License (if different from legal name)

E-mail address

Contact Phone Number: