DISCLOSURE: A CONSUMER REPORT MAY BE PROCURED FOR INVESTIGATIVE PURPOSES.

In accordance with the Fair Credit Reporting Act, a consumer report or Investigative consumer report including information about your credit, general reputation, character, or personal characteristics may be obtained. Upon written request, you will be provided with information regarding the nature and details of the report, should it include information about your general reputation, character, or personal characteristics, and a summary of your rights.

RELEASE AND AUTHORIZATION

I voluntarily and knowingly authorize for investigative and/or employment purposes only, any past employer or supervisor, University or institution of learning, administrator, law enforcement agency, state agency, federal agency, credit bureau, private business, military branch or the National Personnel Records Center, the Minnesota Bureau of Criminal Apprehension, fingerprinting, personal reference and/or other persons to give records and information they may have concerning my criminal history, motor vehicle history, driving record history, earnings history, employment records, banking records, credit card transaction records, telephone toll records, credit history, worker’s compensation claims (including from the State of Minnesota), general reputation character, or any information requested to KEYSTONE INTELLIGENCE NETWORK, INC., or its agents or representatives. I voluntarily and knowingly unconditionally release any named or unnamed informant from any and all liability resulting from furnishings of this information. This authorization shall be valid for one (1) year from the date signed and a photographic or faxed copy of this authorization shall be as valid as the original.

Check ONLY the service you want provided:

_ Employment Screening _ SSN Trace

_ Education Verification _ Driving History

_ Credit/Identity Report _ Drug Testing

_ Personal Reference _ Worker’s Comp.

_ Criminal History Check:

County_______________________

State _______________________

Federal _____________________

Last Name: __________________________________________________________________

Please Print

First Name: __________________________________________________________________

Please Print

Middle Name: __________________________________________________________________

Date of Birth: ___________________ Social Security No.:___________________

Current Address: __________________________________________________________________

Street/P.O. Box City State Zip

Precious Address: __________________________________________________________________

Street/P.O. Box City State Zip

Telephone: (Day): ( )______________ (Night): ( )_________________

Signature: __________________________________________________________________