Independent Contractor Law Enforcement

Consumer Report / Investigative Consumer Report

Disclosure and Release of Information Authorization

This is to advise that Baker Tilly Virchow Krause, LLP intends to use a consumer report and/or investigative consumer report for employment purposes (including independent contractor relationships). This disclosure is made pursuant to the Fair Credit Reporting Act, 15 U.S.C. § 1681b(b)(2)(A). Your consent for the procurement and use of such reports is required. Through this document, it is being disclosed to me and I understand that a Consumer Report or Investigative Consumer Report (“Consumer Report”) may be prepared about me as part of my application for employment and/or continued employment. I voluntarily authorize Baker Tilly Virchow Krause, LLP to procure a Consumer Report from TalentWise Solutions LLC (“TalentWise”), and I authorize TalentWise, a Consumer Reporting Agency, and its agents, to retrieve necessary information and prepare such Consumer Report. I understand that a Consumer Report may be prepared summarizing information from personnel files, educational institutions, government agencies, companies, corporations, credit reporting agencies, law enforcement agencies at the international, federal, state or county level, relating to my past activities. I authorize these entities to supply any and all information concerning my background. The information received may include, but is not limited to, academic, residential, achievement, job performance, employment record, attendance, litigation, personal history, character, general reputation, credit reports and standing, driving records, and criminal history records. If my prior employers and/or references are contacted, the report may include information obtained through personal interviews regarding my character, general reputation, personal characteristics, and mode of living. I understand that TalentWise may transmit my personal information to its agents and information sources as necessary throughout the course of business. I may request a list of designated agents by contacting TalentWise at the address listed below. I understand and authorize that some or all of this information about me may be transmitted electronically and, when required, may be transferred across international borders. I understand that supplemental forms and/or authorizations may be required to obtain international information and that host-country and receiving country privacy laws will be observed if information is transferred across international borders. I understand that I have the right to request additional information regarding the nature and scope of the report being prepared. I should direct my request to TalentWise Solutions LLC, 19800 North Creek Parkway, Suite 200, Bothell, WA 98011, USA, in writing, and will receive a written response within 5 days of TalentWise Solutions LLC’s receipt of my written request. I understand that I may request a copy of any report that is prepared regarding me and “A Summary of Your Rights under the Fair Credit Reporting Act.” I may also request the nature and substance of all information about me contained in the files of the consumer-reporting agency. I understand I have the right to inspect those files with reasonable notice during regular business hours and I may be accompanied by one other person. The consumer-reporting agency is required to provide someone to explain the contents of my file. I understand proper identification will be required and I should direct my request to: TalentWise Solutions LLC, 19800 North Creek Parkway, Suite 200, Bothell, WA 98011, USA. Phone 866-***-****. May your current employer be contacted? YES NO Not Currently Employed Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company. California applicants or employees only: By signing below you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report if one is obtained by the Company at no charge whenever you have a right to receive such a copy under California law. Maine and New York: You have the right, upon request, to be informed of whether a consumer report about you was requested by the above-named company. All Other US States: Please contact TalentWise at 866-***-**** or the address above to request a copy of your consumer report.

I authorize Baker Tilly Virchow Krause, LLP to procure a Consumer Report about me from TalentWise Solutions LLC. I hereby certify all the statements and answers set forth are true and complete to the best of my knowledge. I am willing that a photocopy of this authorization be accepted with the same authority as the original; and that if employed by the above-named company this authorization will remain in effect throughout such employment unless prohibited by applicable law or I withdraw my authorization in writing. Signature: Vance Kibe Date: 10/19/2022 3:36 AM

NOTE: Do not provide the following information until you have read and signed the Disclosure and Release of Information Authorization above. The information requested below is needed to conduct your background investigation and IS NOT considered part of your application. PLEASE PRINT CLEARLY.

Last Name

Kibe

First Name

Vance

Middle Name (If none,

please enter N/A)

Lynn

Other Known Names Or Other Names Used

Other First Name Other Last Name

Current Address

5019 Naples Dr.

Apt.

City

Conway

State

SC

Zip

29526

Date of Birth (mm/dd/yyyy)

10/29/1965

Social Security No.

***-**-****

Driver's License No.

104364305

State

SC

Exp Date:

10/29/2026

List any other COUNTRIES, CITIES, and STATES in which you have lived during the previous 7 years

2026Mt. Tremper, NY

List any other LAST NAMES you have used during the previous 7 years List any other LAST NAMES under which you received your GED, high school diploma, or other academic credentials

Have you ever been convicted of, pleaded guilty or no contest to, been placed on probation, fined, imprisoned or incarcerated, or paroled for any offense (e.g., felony, misdemeanor, ordinance violation or forfeiture) other than minor traffic violations? (Note: A conviction will not automatically bar your employment.)

Yes No

If yes, please explain (please include the state/county and date of incident):

Contact this candidate