The purpose of this form is to notify you that a background report will be conducted on you.

(TYPE OR PRINT)

APPLICANT NAME:__________________________________________________________

DATE OF BIRTH:________________

SOCIAL SECURITY:______________

DRIVERS LICENSE NUMBER: _______________________STATE ISSUED:______________

ALIAS / MAIDEN NAMES USED:________________________________________________

PRESENT ADDRESS:___________________________________________________

                                ___________________________________________________

                                ____________________________________________________

In connection with this request I authorize all corporations, credit agencies, education institutions, law enforcement agencies, city, state, county and federal courts and military services to release information about my employment, education, consumer credit history, driving record, criminal record, worker’s compensation and general public history to the person or company with which this form has been filed or their agent, MidSouth Information Services, Inc. This form releases the aforesaid companies from any liability and responsibility for collecting the above information. I further understand that I will be provided a written note if any adverse action is to be taken in whole or in part based on the consumer report.

APPLICANT SIGNATURE:____________________________________ DATE:_______________

WITNESS:________________________________________________  DATE: _______________

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PLEASE INDICATE INFORMATION REQUESTED:  (To be filled out by employer)

_____ Criminal Record Search  ______________________  State (s)  ________________________County (s)

_____ Consumer Credit Report

_____ Driving Record

_____ Other  _________________________________________