Applicant/Employee complete the following

1. In connection with my application for employment, I understand that a consumer report or an investigative consumer report may be requested from DISA Inc. that may include information as to my character, general reputation, personal characteristics, mode of living and credit standing.

a. I understand that as directed by company policy and consistent with the job described, that information such as but not limit to criminal and warrant records, social security number verification, credit and financial information, education, driving history, employment history, personal references, certifications and professional licenses, drug testing results, address history, and workers compensation records may be obtained.

b. I understand that such information may be obtained by direct or indirect contact from former employers, schools, courts, public agencies, or any other agency or institution and through personal interviews with neighbors, friends, associates, acquaintances, or other persons who have such knowledge.

2. Medical and workers’ compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a consumer reporting agency. If so, I will be notified and given the name and address of the agency or the source which provided the information.

3. I acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as valid as the original. This release is valid for most federal, state and county agencies.

4. Additional State Law Notices:

a. California Applicants/Employees Only: I have the right to request a copy of my consumer report from DISA, Inc. by checking this box. The report will be sent directly to me by DISA, Inc. to my most current address listed. I understand that I have the right to inspect visually the files concerning me maintained by an investigative consumer reporting agency during normal business hours upon reasonable notice. The inspection can be done in person if I appear in person and furnish proper identification. I am entitled to a copy of the file for a fee not to exceed the actual cost of duplication. I am entitled to be accompanied by one person of my choosing, who shall furnish reasonable identification. The inspection can also be done via certified mail if I make a written request, with proper identification, for copies to be sent to a specified address. I can also request a summary of the information to be provided by telephone if I make a written request, with proper identification for telephone disclosure. I further understand that the investigative consumer reporting agency shall provide trained personnel to explain to me any of the information furnished to me. I will receive from the investigative consumer reporting agency a written explanation of any coded information contained in files maintained on me. The nature and scope of the investigation is as follows: ______________________________________________________________________________

b. Massachusetts Applicants/Employees Only: The nature and scope of the investigation is as follows: ______________________________________________________________________________. I have a right to obtain a copy of this report. I understand that in the event that I am denied employment based in whole, or in part, on the information obtained in the DISA, Inc. report, I will be provided a copy of the report and a description in writing of my applicable state rights.

c. Maine Applicants/Employees Only: I have the right, upon request, to be informed of whether an investigative consumer report was requested. If requested my report will be obtained from DISA, Inc, 12600 Northborough Drive, Suite 300, Houston, TX 77067, 1-800-752-6432. This is the nearest unit designated to handle inquires for DISA, Inc on any reports issued concerning me. I have the right, under Maine law, to request and promptly receive from DISA, Inc. copies of my consumer report(s).

d. Minnesota Applicants/Employees Only: I have the right to request a copy of my consumer report from DISA, Inc. by checking this box . The report will be sent directly to me by DISA, Inc. to my most current address listed. I also have the right upon my direct request to DISA, Inc. to obtain a complete and accurate disclosure of the nature and scope of the consumer report. The disclosure obtained from DISA, Inc. will be in writing and mailed or delivered within 5 days after the request for the disclosure was received or the consumer report was requested, whichever is later.

e. New Jersey Applicants/Employees Only: The specific nature and scope of the investigation involving personal interviews includes: ________________________________________________________.

f. New York Applicants/Employees Only: I have the right, upon written request, to be informed of whether or not a consumer report was requested. If requested my report will be obtained from DISA, Inc, 12600 Northborough Drive, Suite 300, Houston, TX 77067, 1-800-752-6432. I may inspect and receive a copy of my report by contacting DISA, Inc.

g. Oklahoma Applicants/Employees Only: I have the right to request a copy of my consumer report from DISA, Inc. by checking this box . The report will be sent directly to me by DISA, Inc. to my most current address listed.

h. Washington Applicants/Employees Only: I understand before I am denied employment based in whole, or in part, on the information obtained in the DISA, Inc. report, I will be provided a copy of the report and a description in writing of my applicable state rights.

The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes.