Motor Vehicle Civil Litigation

FAIR CREDIT REPORTING ACT DISCLOSURE

In conjunction with my application for employment (including contract or volunteer services) with you, I understand that you intend to hire SELECTiON.COM® to obtain Consumer Reports and / or Investigative Consumer Reports (Reports) about me as defined in the federal Fair Credit Reporting Act (FCRA). These Reports may include information concerning my academic background, character, credentials, credit capacity, credit standing, credit worthiness, general reputation, mode of living, personal characteristics, reasons for work termination, work experience, work habits and / or work performance. You may also seek information concerning my civil litigation history, criminal record, educational background, employment history, motor vehicle record, and / or worker’s compensation history. I understand that you may rely on the information contained in these Reports in determining whether to extend an offer of employment to me or maintain my employment with you. If you contemplate making an adverse employment-related decision that will affect me based, in whole or in part, upon a Report obtained from SELECTiON.COM®, I will receive a copy of the Report and a written summary of my Consumer Rights under the FCRA before you finalize that decision. I have read the above disclosure and I hereby authorize you, SELECTiON.COM® or its authorized agents to obtain the above referenced information about me. I also authorize all agencies, bureaus, employers, information service organizations and individuals to provide any of the above referenced knowledge or information they have concerning me. This authorization shall remain on file and be valid for the duration of my employment with you. It shall serve as an ongoing authorization for you to obtain Reports about me from SELECTiON.COM®. A photocopy or facsimile of this authorization shall be as valid as the original. Print Name: Date:

Signature:

Notice to Applicants living in CA, OK or MN:

By checking this box, I request to receive a free copy of any Consumer Report ordered about me. E-Mail address: **

** By entering my e-mail address, I authorize SELECTiON.COM® to deliver my Report via e-mail. Notice to California Residents:

Under California Civil Code Section 1786.22, you may view the file maintained on you by SELECTiON.COM® during normal business hours. You may also obtain a copy of this file, either in person or by mail, by submitting proper identification and paying the costs of duplication services. You may also receive a summary of the file by telephone by being able to provide adequate identification as to allow SELECTiON.COM® to determine with reasonable certainty that you are the subject of the Report. SELECTiON.COM® is required to have personnel available to explain your file to you and must explain to you any coded information appearing in your file. If you appear in person, another person of your choice may accompany you, provided that this additional person also furnishes proper identification. SELECTiON.COM®’s Privacy Policy can be viewed at www.Selection.com. THIS FORM IS FOR PERMANENT RETENTION IN PERSONNEL FILE. 02-01-2017 Page 1 of 2

EMPLOYMENT INQUIRY RELEASE

In conjunction with my application for employment (including contract and / or volunteer services) with you, I understand that you intend to hire SELECTiON.COM® to obtain Consumer Reports and / or Investigative Consumer Reports (Reports) about me as defined in the federal Fair Credit Reporting Act (FCRA). These Reports may include information concerning my academic background, character, credentials, credit capacity, credit standing, credit worthiness, general reputation, mode of living, personal characteristics, reasons for work termination, work experience, work habits and / or work performance. You may also seek information concerning my civil litigation history, criminal record, educational background, employment history, motor vehicle record, and / or worker’s compensation history. I understand that you may rely on the information contained in these Reports in determining whether to extend an offer of employment to me or maintain my employment with you. If you contemplate making an adverse employment-related decision that will affect me based, in whole or in part, upon a Report obtained from SELECTiON.COM®, I will receive a copy of the Report and a written summary of my Consumer Rights under the FCRA before you finalize that decision. I have read the above disclosure and I hereby authorize you, SELECTiON.COM® or its authorized agents to obtain the above referenced information about me. I also authorize all agencies, bureaus, employers, information service organizations and individuals to provide any of the above referenced knowledge or information they have concerning me. This authorization shall remain on file and be valid for the duration of my employment with you. It shall serve as an ongoing authorization for you to obtain Reports about me from SELECTiON.COM®. A photocopy or facsimile of this authorization shall be as valid as the original. I agree that any and all disputes arising from any Report shall be brought only in state or federal court in Hamilton County, Ohio and shall be governed by, and construed in accordance with, the laws of the State of Ohio. Signature Date

THE FOLLOWING INFORMATION IS REQUIRED TO CONDUCT THE BACKGROUND INVESTIGATION PRINT NAME - -

Last Name First Name Middle Initial Social Security Number PREVIOUS OR MAIDEN NAME (if applicable) PHONE NUMBER STREET ADDRESS CITY STATE ZIP

DRIVER’S LICENSE NUMBER STATE ISSUED

E-MAIL ADDRESS

List states and counties of residence, other than above, for the past seven (7) years: COUNTY STATE ; COUNTY STATE ; COUNTY STATE

FOR IDENTIFICATION PURPOSES ONLY: Date of birth

My prospective employer understands that age is a protected characteristic and that any age related information requested will not be used as the basis for any employment decision. Notice to Applicants Living in CA, OK or MN

By checking this box, I request to receive a free copy of any Report ordered on me. E-Mail address: **

** By entering my e-mail address, I authorize SELECTiON.COM® to deliver my Report via e-mail. Notice to California Residents:

Under section 1786.22 of the California Civil Code, you may view the file maintained on you by SELECTiON.COM® during normal business hours. You may also obtain a copy of this file, either in person or by mail, by submitting proper identification and paying the costs of duplication services. You may also receive a summary of the file by telephone by being able to provide adequate identification as to allow SELECTiON.COM® to determine with reasonable certainty that you are the subject of the report. SELECTiON.COM® is required to have personnel available to explain your file to you and must explain to you any coded information appearing in your file. If you appear in person, another person of your choice may accompany you, provided that this additional person furnishes proper identification. The SELECTiON.COM® Privacy Policy can be viewed at www.Selection.com.

IF FAXING OR E-MAILING REQUEST, THIS SECTION MUST BE COMPLETED FOR PROCESSING Customer Number:

Contact Person:

Information Requested:

Location or Store Number:

Phone Number:

Date Submitted:

Position Applied For:

Combined Report:

Individual Reports:

Criminal Convictions County(s) and State(s):

Other:

This Form Provided By: SELECTiON.COM®, 155 Tri-County Parkway, Suite 150, Cincinnati, OH 45246. Telephone: 800-***-****; Fax: 888-***-****. For background check entry, send to adzejh@r.postjobfree.com. For employment or education verification purposes, e-mail to adzejh@r.postjobfree.com with applicant’s full name in the subject line.

02-01-2017 Page 2 of 2

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