ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK

(*REQUIRED) This information will be used for background screening purposes only and will not be used as hiring criteria.

I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by The South Bay Fire Department (“Employer”) at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by: Background Screeners of America, 18344 Oxnard Street, Suite 101, Tarzana, CA 91356;

Tel. # 1.877.251.5656; www.backgroundscreeersofamerica.com and/or Employer. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

Washington State applicants only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

Employment and History: Start with your current/last position held

Please use this space to explain any convictions or to add any additional information regarding applicable skills that might be pertinent to the role you are applying for.

I hereby declare the information provided by me in this application is true, correct, and complete to the best of my knowledge. I understand that if I am selected, any mis-statement or omission of fact on this application shall be considered cause for dismissal. I authorize investigation of all statements in this Application.