Adecco Bank of America Page 1 of 3

Request Form
"I have read, understand and agree to the following: The background information that I supply in connection with my employment application
will be verified by Adecco Employment Services, Inc. and/or LexisNexis Screening Solutions (collectively "The Companies") and by mutual
associates to insure that the information that I provide is accurate in every way. The information to be verified includes any and all information
supplied on any application forms, addendums or resume, and information provided in any conversation or interview with any employee of The
Companies. This may include discussions with references (personal or business) that I provide. I authorize The Companies and/or their agents
to conduct a thorough inquiry into all areas deemed necessary to arrive at a hiring decision or decision regarding placing me on assignment
including but not limited to all employment and public record information relating to my application and/or addendum may be examined. I
specifically release Adecco Employment Services, Inc. ("Adecco"), LexisNexis Screening Solutions, Bank of America, employers, criminal
information repositories and courts, schools, law enforcement agencies, local, state and federal administrators, credit bureaus, institutions or
persons from any liability so that they may freely and completely respond to any inquiry relating to my application for employment with Adecco
and/or consideration for any assignments through Adecco. I certify that all information provided on this Background Request Form is true and
complete. I understand that any omission or misinformation on this form, my application and/or my addendum may prohibit my employment or
be the grounds for immediate termination whenever such omission or misinformation is discovered."
Signature__________________________________________________________ Date____________________________
Social Security Number Last Name

***** Select ONE package option from the following ******

Select the skill set below that is reflected on the Job Posting in Fieldglass.
#1 Staffing Partner Packages
For packages requested in these skill categories, the MSP Subcontractor Company
(Staffing Partner) that submits the screening will be charged.
Account # Location

2 1 9 3 4 9 1 2 6
Requester Name

Voice Telephone Number Fax Number

Optional Search
(Only when required)
GSA
Staffing Partner Packages
Creative Finance & Accounting (I & II) Professional System Administrator
Data Consultant Legal ( I & II) Programmer Systems Analyst
Developer Light Industrial Project Management Technical Support
Engineer Network QA

#2 Bank of America Packages

Bank of America will be billed directly for these screenings.
Account # Location BOA Company # BOA Cost Center #

2 1 9 3 4 9 1 2 6B OA 0 0
Requester Name

Voice Telephone Number Fax Number

Bank of America Packages Optional Search

(Only When required)
Call Center CRE / Mortgage
Clerical Payroll
GSA
Revised 9/4/09 FAX to LexisNexis Screening Solutions at 1-800-699-4874 AND Adecco Compliance at 1-631-844-7551
For LexisNexis Assistance call Adecco.Support at 1-866-438-5647 or e-mail Adecco.Support@choicepoint.com
 Adecco Bank of America Page 2 of 3
Request Form
Social Security Number

Last Name

Personal Information...Print capital letters in the boxes. Try not to touch the sides of the boxes.

A B CD E F G H I J K LMN O PQ RS T U VWX YZ
First Name

Middle Name

Last Name

Previous Legal Name Within Last 10 Years

City of Current Residence State Zip

County of Current Residence

Social Security Number Date of Birth (month-day-year)

Driver's License Number State

Requester Name

Voice Telephone Number Fax Number

Account # Location

2 1 9 3 4 9 1 2 6

FAX to LexisNexis Screening Solutions at 1-800-699-4874 AND Adecco Compliance at 1-631-844-7551

For LexisNexis Assistance call Adecco.Support at 1-866-438-5647 or e-mail Adecco.Support@choicepoint.com
Revised 9/4/09
 Adecco Bank of America Page 3 of 3
Request Form

Social Security Number

Last Name

Current and Previous cities lived and worked for the last 10 years.
City State Zip

City State Zip

City State Zip

City State Zip

City State Zip

City State Zip

City State Zip

City State Zip

City State Zip

City State Zip

City State Zip

Requester Name

Voice Telephone Number Fax Number

Account # Location

2 1 9 3 4 9 1 2 6

FAX to LexisNexis Screening Solutions at 1-800-699-4874 AND Adecco Compliance at 1-631-844-7551

For LexisNexis Assistance call Adecco.Support at 1-866-438-5647 or e-mail Adecco.Support@choicepoint.com
Revised 9/4/09