I. In connection with my application for employment at CenCon of Kansas, L.L.C, I understand  that an investigative consumer report may be requested that will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment. I understand that as directed by company policy and consistent with the job described, you may be requesting information from public and private sources about my workers’ compensation injuries, driving record, court record, education, credentials, credit, and references.

II. 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.

III. 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, including the Minnesota Department of Labor.

IV. Minnesota, Oklahoma, and California applicants only. If you want a copy of the report(s) ordered, check this box below. The report(s) will be sent by the reporting agency to you at the address below.

V. I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by CenCon of Kansas, L.L.C or its agent, to furnish the information described in Section I.

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. I hereby release the employer and agents, and all persons, agencies, and entities providing information or reports about me from any and all liability arising out of the request for or release of any of the above mentioned information or reports.

The following state require sex and race to obtain information: AL, AR, FL, IA, IL, IN, MI, OR, TX, WI

Property of CenCon of Kansas L.L.C     Confidential