NOTIFICATIONAIELEASE O1? INFORMATION FORM The purpose of this form is to notify you that consumer report will be conducted on you in the course of consideration for employment with: Last Name: First Name: Pi\idtu Social Security #: Current Address: City: Middle Name: State of Issue: State: al Zip: In connection with this request I authorize all corporations, former employers, credit agencies, educational institutions, law enforcement agencies, city, state, county, and federal courts and military services to release information about my background including, but not limited to information about my employment, education, consumer credit history, driving record, criminal record and general public history to the person or company with which this form has been filed, or their agent. This releases the aforesaid parties from any liability and responsibility for collection of the above information. APPLICANT'S SIGNATURE: DATE: 1 \ 3 \ \\Lk EFTA00606108