Prior Injury and Disability Questionnaire
(Step 9 of 9)

The Fair Credit Reporting Act requires that we inform you that a background investigation may be conducted as part of our screening and hiring process. This may include an inquiry to obtain information regarding your character, employment history, general reputation, personal characteristics, police record, education, qualifications, motor vehicle record, mode of living and/or credit and indebtedness. The primary objective of any investigation will be to verify information you provided on your application or during the interview process or during your employment with this company. Upon timely written request to our personnel department, and withing 5 days of the request, the name, address and phone number o0f the reporting agency and the nature and scope of the report (if one is made) will be provided to you. You have the right to request details of the report from the consumer-reporting agency. Before any adverse action is taken, based in whole or in part on the information contained in the consumer report, you will be provided a copy of the report, the name, address and telephone number of the reporting agency, a summary of your rights under the Fair Credit Reporting Act, as well as additional information on your rights under the law. The items of information requested below are required to process your background investigation. They are intended solely for that purpose and will not be used in a discriminatory manner for the making of business decisions. (A Copy of ‘A Summary of Your Rights Under the Fair Credit Reporting Act’ is included with this authorization)