Background Search Release Authorization
And Fair Credit Reporting Act Disclosure
Name:
Address:
City:		State:	Zip:
Social Security Number:
Date of Birth
Driver License Number:			State:
Former, Prior, and Maiden Names		(list all and dates of changes):
Prior Addresses	(list all from the past 7 years, including dates):
I voluntarily consent to and authorize Diversified Drilling Corporation, hereinafter referred to as the Company, and/or their assigned Agents, Associates, or Consumer Reporting Agencies to request and receive any information concerning me, including but not limited to a Criminal History Search, reports from any Persons, Schools, Companies, Corporations, Partnerships, Associations, Consumer Credit Reporting Agencies or Bureaus, Motor Vehicle/Driving Records, Licensing Agencies, Courts of Law, and any current or former Employer. This authorization is valid throughout the course of my employment with the Company.
I authorize any of the above parties to furnish the Company and or their assigned agents and associates with any and all information concerning me. I further agree to release and otherwise hold harmless the Company and/or their assigned agents or associates from any and all liability and responsibility arising out of the release of such information in connection with this research.
I understand that I have specific prescribed rights as a consumer under The Federal Fair Credit Reporting Act (FCRA) and may have additional rights under relevant specific state laws. This authorization does not include a release of my medical information. I further acknowledge and certify that I have received a summary of my rights under the Fair Credit Reporting Act (FCRA).
The above is understood and agreed by:
Signature		Printed Name		Date