BACKGROUND REPORT RELEASE FORM
PLEASE READ CAREFULLY

This is to notify you that in connection with your application for employment or temporary assignment we may produce a consumer report. Please be advised that we may also obtain an investigative consumer report including information as to your character, general reputation, personal characteristics and mode of living as part of the process. In the event that information gained from these reports is utilized, either in whole or in part, in making an adverse decision we will provide you with a copy of the consumer report and a description of your summary of rights under the Fair Credit Reporting Act (FCRA) before making an adverse action.

This information may be obtained by contacting your present and previous employers or references supplied by you. The report may cover information including, but not limited to, credit reports, criminal history reports, and any public records i.e. driving records, education and licensing verifications, personal reference verifications, federal and state blocked party information, medical professional sanctions and Social Security number verification.

Please be advised that you have the right to request a copy of the consumer report in a reasonable amount of time (60 days). We will make a complete and accurate disclosure of the nature and scope of the information requested.

By signing below, I am authorizing Citizens Telephone Cooperative to prepare a consumer or investigative consumer report on me as part of the screening process for employment or temporary assignment. During the period in which I retain employment or assignment, I further authorize Citizens Telephone Cooperative to obtain additional consumer reports or investigative consumer reports on me to evaluate my reliability for purposes of determining continued access authorization. I also acknowledge that Citizens Telephone Cooperative will provide me with a copy of my summary of rights under the fair credit-reporting act (FCRA) if needed.

I additionally authorize all entities having information about me including present and former employers, criminal justice agencies, department of motor vehicles, schools, and credit reporting agencies to release such information to the below indicated party or Citizens Telephone Cooperative and to Partnership Screening as the investigative consumer reporting agency, or to any firm retained to conduct such investigations, with all to be treated as the end user of such information without exception.

Name of Requester CitizensTelephone Cooperative

This release and authorization shall remain valid and in effect during the term of your employment. We reserve the right to run additional consumer reports and/or investigative consumer reports on an as needed basis.

For residents of, or for jobs located in, California, Maine, Massachusetts, Minnesota, New Jersey, New York, Oklahoma and Washington, you may request a free copy of any background check report by checking the box below.

The information that you provide on this form will be used solely for the purpose of identifying or eliminating possible records revealed during the background screening process and will not be used in any way in making an employment or assignment decision