Authorization to Conduct Employment Background Investigation

I hereby authorize Justifacts Credential Verification, Inc, an Agent for INSERT CLIENT NAME to ascertain information regarding my background to
determine any and all information of concern to my record, whether same is of record or not, and I release employers and persons named in my application from
all liability for any damages on account of his/her furnishing said information. I understand that this form indicates that a background search will be conducted
and that this is my notification of that intent. I understand that the purpose of this background investigation is to determine my suitability for employment and
may elicit information on my character, general reputation, personal characteristics and mode of living. Additionally, you are hereby authorized to make any
investigation of my personal history, educational background, military record, motor vehicle records, criminal records and credit history through an investigative
or credit agency or bureau of your choice. I authorize the release of this information by the appropriate agencies to the investigating service. I understand that my
consent will apply throughout my employment, unless I revoke or cancel my consent by sending a signed letter or statement to the Company at any time, stating
that I revoke my consent and no longer allow the Company to obtain consumer or investigative consumer reports about me.

PLEASE PRINT CLEARLY

FULL NAME:

OTHER NAMES USED/MAIDEN NAME/DATES:

LIST ALL ADDRESSES FOR PAST 7 YEARS:

Dates:

Dates:

EMAIL ADDRESS: __________________________________

SOCIAL SECURITY # DATE OF BIRTH:

DRIVER’S LICENSE # STATE ISSUED:

*** MAY WE CONTACT YOUR CURRENT EMPLOYER? YES _______ NO

*** HAVE YOU EVER BEEN CONVICTED OF A CRIME? YES _______ NO

If yes, please explain:

Notice to California Applicants - You may omit minor traffic offenses, any convictions which have been sealed, expunged or statutorily eradicated,
convictions more than two years old for the following marijuana related offenses: HS11357b&c, HS11360c, HS11364, HS11365, HS11550, and misdemeanors for
which probation was completed and the case was judicially dismissed.

Notice to Massachusetts Applicants: You may omit a first conviction for any of the following misdemeanors: drunkenness, simple assault, speeding, minor traffic
violations, affray, or disturbance of the peace, or any conviction of a misdemeanor where the date of such conviction or the completion of any period of incarceration
resulting there from, whichever date is later, occurred five or more years prior to the date of this application for employment, unless you have been convicted of any offense
within five years immediately preceding the date of this application for employment.
Note: No applicant will be denied employment solely on the grounds of conviction of a crime. The nature of the offense, the date of the offense, the
surrounding circumstances and the relevance of the offense to the position will be considered.

SIGNATURE: DATE:
California Applicants: Under Section 1786.22 of the California Civil Code, you have the right to request from Justifacts (5250 Logan Ferry Rd, Murrysville PA 15626 – 800-356-6885,
www.justifacts.com), upon proper identification, the nature and substance of all information in its files on you, including the sources of information, and the recipients of any reports on you to
whom Justifacts has previously furnished within the three-year period preceding your request. Files maintained on a consumer shall be made available for the consumer's visual inspection, as
follows: (1) In-person, if he appears in person and furnishes proper identification. A copy of his file shall also be available to the consumer for a fee not to exceed the actual costs of duplication
services provided. (2) By certified mail, if he makes a written request, with proper identification, for copies to be sent to a specified addressee. (3) A summary of all information contained in files on
a consumer and required to be provided by Section 1786.10 shall be provided by telephone, if the consumer has made a written request, with proper identification for telephone disclosure, and the
toll charge, if any, for the telephone call is prepaid by or charged directly to the consumer.
California, Minnesota & Oklahoma Applicants Only: Please check this box if you would like a copy of the background check mailed to you. Minnesota and Oklahoma applicants will
receive a copy direct from Justifacts or its designee. California applicants may receive a copy from either the prospective employer or Justifacts.

NOTICE: Under federal law, you have the right to request disclosure of the nature and scope of our investigation by providing us with a written request within 60 days of our background
investigation.
Subscriber certifies that consumer credit information, consumer reports, as defined by the Fair Credit Reporting Act, 15 U.S.C. 1681 at seq. (“FCRA”), will be ordered only
when intended to be used as a factor in establishing a consumer’s eligibility for employment and that consumer credit information will be used for no other purposes. It is
recognized and understood that the FCRA provides that anyone “who knowingly and willfully obtains information on a consumer from a consumer reporting agency”
(such as Justifacts) “under false pretenses shall be fined not more than $2,500 or imprisoned not more than two years or both.”