Fair Credit Reporting Act Authorization/Disclosure - All applicants are required to sign this document prior to the initiation of a background investigation. National Profiles does require a signed copy.

National Profiles Incorporated

Background Investigation Authorization/Disclosure

I authorize National Profiles Incorporated, a Consumer Reporting Agency or any of its agents to procure an investigative consumer report for employment purposes, which may include information about my character, background, general reputation, personal characteristics, or mode of living.  I understand that I have the right to request, in writing, information pertaining to the nature and scope of the investigation and a written summary of my rights under the Fair Credit Reporting Act.  I understand that before adverse action, including the denial of my employment can be taken against me in whole or in part due to a consumer report, I will be provided with a copy of the report and a written summary of my rights under the Fair Credit Reporting Act.  I also understand I may have additional rights under applicable state law.

I authorize all government agencies, state department of motor vehicles, corporations, companies, educational institutions, persons, law enforcement agencies, workers’ compensation agencies, criminal, civil and federal courts, and former employers to release information they may have about me and release them from any liability and responsibility from doing so.  Any copy of this authorization shall have the same authority as the original.

Signature                                                                                                             

Date                                                                                                       

Other information: Please print clearly                                                   Address information: Please print clearly

Name (First, MI, Last)                                                                                       Current address (number and street)            

Maiden or other names used and dates used*                                                          Current address (Town, State, Zip)

                                                                                                                                From:                              To:                 

Social security number                                                                                   First prior address (number and street)    

                                                                                                                First prior address (Town, State, Zip)

                                                                                                                                From:                              To:                 

Drivers license number and state                                                                 Second prior address (number and street)    

Second prior address (Town, State, Zip)

                                                                                                                From:                              To:                 

* Date of Birth (for criminal check)                   

                                                                ____________________________________

                                                                                                                                Third Prior address (number and street)    

                                                                                                                                                                                                                                                                                                                                                Third Prior address (Town, State, Zip)

                                                                                                                                From:                              To:                 

*This information will be used for purposes of identification only.  Federal law prohibits discrimination in employment on the basis of age, race, creed, religion, sex, or national origin.  Many states also prohibit some or all of the above types of discrimination and discrimination based in marital status.