In connection with my application for employment (including contract for services), I understand that consumer reports or investigative consumer reports which may contain public record information may be requested or made on me including consumer credit, criminal records, driving record, education, prior employer verification, workers compensation claims and others. These reports will include experience along with reasons for termination of past employment. Further, understand that information from various Federal, State, local and other agencies which contain your past activities will be requested.

By signing below, you hereby authorize without reservation, any party or agency contacted by this employer to furnish the above mentioned information. You further authorize ongoing procurement of the above mentioned reports at any time during your employment (or contract). You also agree that a fax or photocopy of this authorization with your signature be accepted with the same authority as the original.

I have the right to make a request of INTELLICHOICE, INC., upon proper identification and the payment of any authorized fees, for the information in its files on me at the time of my request.

For California applicants only, if you would like to receive a copy of the credit report, if one is obtained, please check this box. For Minnesota or Oklahoma applicants only, if you would like to receive a

copy of the consumer report, if one is obtained, please check this box.

Print your name _________________________________________________________

Current Address _________________________________________________________

City________________________________________ State____ ZIP_____________

Social Security Number_____________________

Drivers License State ____ License number_______________________________


For identification purposes

Date of Birth Month____ Day_____ Year ____ Race____ Gender M F

Other or former names____________________________________________________


Signature______________________________________________ Date ____________


Previous Addresses in last 7 years


Street Address City State Zip


Street Address City State Zip


Street Address City State Zip