Consent to the Obtainment of State Police Records

and FBI Fingerprinting and Background Checks

I consent that Therapy Staff (member of Aequor Healthcare Services LLC) and all its subsidiaries may conduct a criminal history check on me that includes the review and obtainment of State Police records, fingerprints and an FBI background check. This consent has been granted pursuant to my receipt of a good faith offer of employment or contract. I also agree to provide personal identification acceptable to the State Police. Name: Last First Middle Maiden/Previously Used Name

Birth Date: Place of Birth (State): Country of Citizenship: Height (ft/in.): Weight (lbs.): Hair Color: Eye Color: Gender: Race: Social Security Number: Address: Street City State Zip Code County

Have you continuously resided in the above state within the last year? Yes or no (circle one) Occupation: Driver’s License Number: State Issued

Professional License Number: I attest that the above information is true to the best of my knowledge. I agree that providing false information can lead to immediate termination.

Print Name

Signature Date