Public and Private Record Release

State and Federal privacy laws protect and prescribe restrictions regarding access to certain confidential and personal information. This form authorizes the release of motor vehicle and criminal background information to the Organization named below for employment or insurance eligibility purposes. By signing below: I authorize Organization to investigate and review driving, motor vehicle, criminal histories and related information periodically the duration of my employment or insurance relationship with the Organization; I understand that my employment or insurance eligibility is contingent upon the Organization review of such information; and I confirm that I have read and understand the attached Disclosure statement.

DISCLOSURE STATEMENT

When considering your application for employment, insurance or credit, when making a decision whether to offer you employment, insurance or credit, when deciding whether to continue your employment, insurance or credit, and when making other decisions directly affecting you, may wish to obtain and use a "consumer report" from a "consumer reporting agency". These terms are defined in the FCRA (15 US.C. SS 1861 et seq.), which applies to you. You are a "consumer" with rights under the FCRA. A "consumer" is an individual. A "consumer reporting agency" is any person or business which for monetary fees, dues, or on cooperative nonprofit basis, regularly engages in whole or in part in the practice of assembling or evaluating consumer credit information or other information on consumers for the purpose of furnishing "consumer reports" to others, and which uses any means or facility of interstate commerce for the purpose of preparing or furnishing "consumer reports". A "consumer report" is any written, oral, or other communication of any information by a "consumer reporting agency" bearing on a consumer's credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected, in whole or in part, for the purpose of serving as a factor in establishing the consumer's eligibility for employment purposes or other purposes authorized under the FCRA. If the Organization obtains a "consumer report" about you, and if, based on any information in the consumer report, the Organization makes a decision for employment, insurance or credit purposes that directly and adversely affects you, you may be provided with a copy of the "consumer report". You may also contact the Federal Trade Commission about your rights under the FCRA as a "consumer" with regard to "consumer reports" and "consumer reporting agencies". The Organization has contracted with SAMBA Holdings, Inc. to provide records. SAMBA furnishes information as available from state and national agencies. SAMBA does not issue an opinion on the information provided, or participate in any action or decision based on the information provided. SAMBA may be contacted in writing concerning a consumer report about you: In writing: SAMBA Holdings, Inc. 1730 Montanþo NW Suite F Albuquerque, NM 87107