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Pre-Employment Disclosure, Authorization, and Release The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for other purposes. Applicant’s Full Name________________________________________________________

_______________________ Any other NamesUsed________________________________________________________

______________________ Social Security Number _______________________________ Date of Birth __________________________________ Current Address_____________________________________________________

_______________________________ City_____________________________ State_______________________ Zip_________________________________ Driver’sLicense No.______________________________________ State_____________________________________ High School, College, University or Institution of Professional Training_________________________________________ Campus Name ______________________________ Campus City___________________ Campus State ___________ Name used at the Institution or School__________________________________________________________________ Dates of Attendance__________________________________________________

______________________________ My present employer may be contacted for a Job Reference _________ Yes ________ No

Pursuant to the requirements of the Fair Credit Reporting Act, I understand and acknowledge that a credit report, consumer report, and/or investigative consumer report may be made in connection withmy application for employment with the City of La Porte. I understand that these investigative background inquiries may be made from public and private sources and include records related to credit, consumer, criminal, driving, workers’ compensation injuries, education, credentials, and prior employment, and additionally, may include information as to my character, work habits, performance andexperience, along with reasons for termination of past employment from previous employers. Further, I understand that the City of La Porte may be requesting information from various Federal, state and other agencies which maintain records concerning my past activities relating to my educational/school records, driving, credit, criminal, civil and other experiences, as well as claims involving me inthe files of insurance companies. I authorize, without reservation, any party or agency contacted by Publicdata.com and/or the City of La Porte, or any of there respective agents, to furnish the information mentioned above. A photocopy of this authorization shall have the same effect as the original. I understand the information obtained will be used as one basis for employment or denial ofemployment. In consideration of the opportunity to be considered for employment by the City of La Porte I hereby agree to discharge, release, hold harmless, and indemnify the City of La Porte, Publicdata.com, their agents and employees, and all parties that rely on this release and/or the information obtained with this release from any and all claims, causes of action, liability and/or damages arising byreason of requests for or release of any of the above mentioned information or reports, the use of this release, and/or dissemination of information that is false and untrue if obtained from a third party without verification. It is expressly understood that the information obtained through the use of this release will not be verified by Publicdata.com or the City of La Porte. I further authorizeongoing procurement of the above mentioned reports at any time during my employment. I have read and understood the above information, and assert that all information provided by me is true and accurate. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative report. I acknowledge...