Order Filler Law Enforcement

GCD-*** - Order Filler-S*****

May **, ****

Background Form

FAIR CREDIT REPORTING ACT

BACKGROUND DISCLOSURE AND AUTHORIZATION KC Office

As an employment applicant or current employee of Associated Wholesale Grocers, Inc. ("AWG"), you are a consumer with rights under the Fair Credit Reporting Act ("FCRA"). A "Summary of Your Rights Under the Fair Credit Reporting Act" issued by the Consumer Financial Protection Bureau is attached. You should read this form and the Summary carefully. When considering your employment application, making a decision whether to offer employment, deciding to continue employment (if hired), or making other employment decisions directly affecting you, AWG may obtain and use information contained in either a consumer report or an investigative consumer report from a consumer reporting agency ("CRA"). If an investigative consumer report is requested, you will receive an additional disclosure and may request additional information about the nature and scope of such investigation. AWG generally conducts its own backgrounds checks and obtains such information directly. However, it may obtain consumer reports from CRA: Data Facts Inc. . Information that may be obtained includes, without limit, SSN verification, residential history, credit report, criminal/conviction and driving history, academic experience, job performance, attendance and disciplinary history, and verification of employment experience. Such information may be obtained from private and/or public records or sources including, without limit, sources identified in your application, education or financial institutions, law enforcement or government agencies, divisions of motor vehicles, social networking or internet sites, and consumer reporting agencies. If obtained, you may request, with proper identification, a copy of your consumer report and file by contacting CRA: Data Facts, Inc. PO Box 4276 Cordova, TN 38088-4276. AUTHORIZATION

By signing below, you (1) acknowledge you have carefully read this Background Disclosure and Authorization and understand that you have rights under the FCRA including those discussed above; (2) without reservation, voluntarily authorize AWG to obtain consumer reports or investigative consumer reports about you from a consumer reporting agency, and (3) voluntarily consent to the release of such consumer reports or investigative consumer reports to AWG and to AWG considering this information when making decisions regarding your application or employment. By signing below, you further (4) without reservation, voluntarily authorize and request any present or former employer, education or financial institution, law enforcement or government agency, division of motor vehicles, consumer reporting agency or other persons or agencies having knowledge about you to furnish AWG and/or its CRA with any and all background information about you in their possession so your employment qualifications may be evaluated and/or reassessed; and, (5) voluntarily authorize AWG and/or its CRA to request and obtain background information about you from any source.

By signing, you further agree that a photocopy, electronic copy or fax of this signed authorization will be as valid as the original for any report or information that may be requested. Legal First Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cafrey Legal Middle Name .

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(Some positions may require that you have a license) Yes

Driver's License Number .

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E-Signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cafrey Delco Accepted

Previous Address

Addresses Within The Past Seven Years

Present Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 Masters Point Court Address 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Slidell State . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Louisiana Zip/Postal Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70458 Previous Address 1

Previous Street Address .

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Enter Any Other Names Used (including maiden names and nicknames) Other Names Used 1

First Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Middle Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CJ Last Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Contact this candidate