Disclosure and Authorization Form

Disclosure Regarding Background Investigation

IMPORTANT!  Please Read Carefully Before Signing Authorization 

Hydrosol System, Inc. (“the company”) may obtain information about you for employment purposes from a third party consumer reporting agency. Thus, you may be subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends or associates. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment history, or other background checks. You have the right, upon written request made with a reasonable amount of time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by LexisNexis Screening Solutions Inc. P.O. Box 1050108, Atlanta, GA 30348-5108, 1-800-845-6004. The scope of this notice and authorization is all-encompassing, however, allowing the Company to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your rights to request disclosure of the nature and scope of any investigative consumer report. Acknowledgment and Authorization I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR 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 Company 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 LexisNexis Screening Solutions, Inc., P.O. Box 105108, Atlanta, GA 30348-5108, 1-800-845-6004, another outside organization acting on behalf of the Company, and/or the Company itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

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Consumer Information *This information will be used for background screening purposes only and will not be used as hiring criteria. 

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