Contractor Authorization to Release Information

I__________________________________________________________________hereby
authorize Thermo Fisher Scientific/CastleBranch, Inc. it’s agent, or any agent/assigns of their
company, to contact any of my previous employers, schools, individuals and/or persons,
educational institutions, private companies, businesses and or corporations, credit reporting
agencies, local, state, and federal law enforcement and governmental agencies to supply Thermo
Fisher Scientific/CastleBranch, Inc. it’s agent, or any agent/assigns of their company any
information maintained in their records concerning my background and character. I also hereby
release any of the above from any liability and responsibility arising from doing so.

I also hereby authorize, as a condition of employment or as part of my duties relating to

employment, site access for the release of all appropriate background information regarding my
Personal Credit History, Criminal Record History, Driving Record History, Workers Compensation
Claim History, Educational Records and/or any other applicable information permissible under the
Fair Credit Reporting Act, 15 U.S.C. Sec. 1681 et seq, (FCRA), Federal Trade Commission
interpretations of the FCRA, and all local, state and federal governing laws pertaining to
employment, insurance or credit history. I understand that any job offer, or if hired my continued
employment or Site access, may be conditioned upon a medical examination and/or alcohol or
drug testing and a background/security clearance (including Controlled Substance).

I understand that the information will be used for the purposes of verifying information as
stated by me on my resume, application for employment, or site access and or any other
documentation completed by me for the purpose of investigating and verifying my background.
The information contained in my Consumer Report may be used for decisions related to my
employment or site access.

I believe that to the best of my knowledge and ability that all of the information I have
provided pertaining to my personal background and history is accurate, true and correct and that I
fully understand the terms of this release.

(Please Print Clearly)

______________________________________________________________________
Emmanuel
First Name Middle Name Last Name

Alias or Maiden Name:_________________________________ Sex: Male/Female

(Circle One)

____________________ * _____/_____/19____ _____________________________

Social Security Number Date of Birth Driver’s License Number / State

_______________________________ ________________________ _______ _____

Current Address City State Zip

Signed on this ________ day of ______________________, in the year 20______

Signature: ___________________________________

Email Address: ___________________________________

Company Name: ___________________________________

Effective 2017
 DISCLOSURE OF INTENTION TO OBTAIN
CONSUMER REPORT FOR EMPLOYMENT PURPOSES

This disclosure is being provided to you pursuant to the Fair Credit

Reporting Act, 15 U.S.C. § 1681b(2)(A).

In connection with your application for employment and, if you are

employed, at any time during your employment, _______________ may
obtain a consumer reports (including but not limited to credit reports and
criminal background checks) regarding you.

AUTHORIZATION FOR ________________ TO OBTAIN

CONSUMER REPORTS FOR EMPLOYMENT PURPOSES

Pursuant to 15 U.S.C. § 1681b(2)(A), I hereby expressly authorize

___________________:

1. To obtain consumer reports regarding me for employment purposes in

connection with the evaluation of my application for employment, and

2. To obtain consumer reports regarding me during my employment, if I

am employed by __________________.

This ___ day of _____________.

_______________________
Applicant’s signature

_______________________
Applicant’s name printed

Effective 2017
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 ____ California, Minnesota & Oklahoma Applicants Only: Please check here
to have a copy of your consumer report sent directly to you by CastleBranch, Inc.
at the address listed above. Minnesota and Oklahoma applicants will receive a
copy directly from CastleBranch, Inc. California applicants may receive a copy
from either the prospective employer or CastleBranch, Inc.

*Date of birth is being requested to ensure accurate retrieval and

verification of records. This information is used for positive identification
only and is not a means of qualification or disqualification for employment. Under
Federal law, you need not provide this information and your refusal to provide
this information cannot be used to make any adverse decision.

Notice to CALIFORNIA Applicants

Under Section 1786.22 of the California Civil Code, you have the right
to request from CastleBranch, Inc., upon proper identification, the
nature and substance of all information in its files on you, including the
sources of information, and the recipients of any reports on you, which
CastleBranch, Inc. has previously furnished within the two-year period
preceding your request. You may view the file maintained on you by
CastleBranch, Inc. during normal business hours. You may also obtain a
copy of this file upon submitting proper identification and paying the costs
of duplication services. Upon making a written request, you may receive a
summary of your report via telephone.

Notice to NEW YORK Applicants

Under Article 25 Section 380-g of the New York General Business Law,
should a consumer report received by an employer contain criminal
conviction information, the employer must provide to the applicant or
employee who is the subject of the report, a printed or electronic copy of
Article 23-A of the New York Correction Law, which governs the
employment of persons previously convicted of one or more criminal
offenses.
______ Please initial here to acknowledge receipt of Article 23-A of
the New York Correction Law.

Effective 2017
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****List the addresses of your residence for the past 7 years. Include the number of years
and months.
****If you have lived outside of the USA, please provide your full international address
and mother’s maiden name (located at bottom of form).

Present Address Length at address from: Years, months to present

City State Zip

Previous Address Length at address from: Years, months

City State Zip

Previous Address Length at address from: Years, months

City State Zip

Previous Address Length at address from: Years, months

______________________________________________________________________________
City State Zip

Previous Address Length at address from: Years, months

City State Zip

International address:

Previous Address Length at address from: Years, months

City State Zip

Mother’s Maiden Name:

_________________________________________

Effective 2017
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