COMPANY USE ONLY

GRADE: ____________

11/12/2015
BACKGROUND VERIFICATION DISCLOSURE

DATE RECEIVED: ___________

As part of the employment process, The Company may obtain a Consumer Report and/or an Investigative Consumer Report. The Fair Credit Reporting
Act as amended by the Consumer Reporting Reform Act of 1996 requires that we advise you that for purposes of employment only, a Consumer Report
may be made which may include information about your credit standing, credit capacity, character, general reputation, personal characteristics, or mode
of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided, in the event the Report
contains information regarding your character, general reputation, personal characteristics, or mode of living. When an offer is extended it will be
contingent upon successful completion of this background screen. Minnesota/California/Oklahoma residents only. If you want a copy of the consumer
report ordered, check here ____ . The report will be sent by the consumer reporting agency to you at the address listed below.The Consumer Report
and/or Investigative Consumer Report will be conducted by General Information Services, Inc. (GIS). Their contact information is:
PO Box 353 Chapin, SC 29036
888-333-5696
www.geninfo.com
AUTHORIZATION AND RELEASE
During the application process and at any time during any subsequent employment, I hereby authorize General Information Services, Inc. (GiS), on
behalf of The Company, to procure a Consumer Report which I understand may include information regarding my credit worthiness, credit standing,
credit capacity, character, general reputation, personal characteristics, or mode of living. This report may be compiled with information from credit
bureaus, court record repositories, departments of motor vehicles, past or present employers and education institutions, governmental occupational
licensing or registration entities, business or personal references, and any other source required to verify information that I have voluntarily supplied. I
understand that I may request a complete and accurate disclosure of the nature and scope of the background verification to the extent such investigation
includes information bearing on my character, general reputation, personal characteristics, or mode of living.

APPLICANT PLEASE PRINT

Name (First/Middle/Last): _________________________________________________________
Signature: _____________________________________________
Date Signed: __________________
APPLICANT PLEASE PRINT ALL SUBSEQUENT INFORMATION
Previous Legal Name in the Past 7 years: _____________________________________________________
__________________________
Social Security Number

_______________________
Date of Birth (mm/dd/yyyy)

Current Address: __________________________________________________________________________

_________________________
City

_______________
State

________________
Zip Code

Previous Address: __________________________________________________________________________

_________________________
City

_______________
State

________________
Zip Code

REQUESTER INFORMATION
Requesters User ID: ___________________

GiS Account Number: _________

Check One:
This is an Internal Applicant

Store Number: ________________

This is an External Applicant

Work State: ___________________