Application

P.O. Box 242 Rocky Hill, New Jersey 08553

Phone: (732) 500-7891

(IMPORTANT – PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION)

DISCLOSURE AND AUTHORIZATION OR CONSUMER REPORTS

In connection with my application for employment (including contract or volunteer services) with Bench

Staffing LLC, I understand consumer reports will be requested by (The Company). These reports may

include, as allowed by law, the following types of information, as applicable: names and dates of previous

employers, reason for termination of employment, work experience, reasons for termination of tenancy,

former landlords, education, accidents, licensure, credit, etc. I further understand that such reports may

contain public record information such as, but not limited to: my driving record, workers’ compensation

claims, judgments, bankruptcy proceedings, evictions, criminal records, etc., from federal, state, and other

agencies that maintain such records.

In addition, investigative consumer reports (gathered from personal interviews, as applicable, with former

employers or landlords, past or current neighbors and associates of mine, etc.) to gather information

regarding my work or tenant performance, character, general reputation and personal characteristics, and

mode of living (lifestyle) may be obtained.

If I am hired, I understand that my employer can use this disclosure and authorization to continue to

obtain such consumer reports throughout my employment, contract period or volunteer service.

Authorization

I hereby authorize procurement of consumer report(s) and investigative consumer report(s) by

Company. If hired (or contracted), this authorization shall remain on file and shall serve as ongoing

authorization for Company to procure such reports at any time during my employment, contract,

or volunteer period. I authorize without reservation, any person, business or agency contacted by

the consumer reporting agency to furnish the above- mentioned information.

This authorization is conditioned upon the following representations of my rights:

I understand that I have the right to make a request to the consumer reporting agency:

telephone number

, upon proper identification, to obtain copies of any reports furnished to Seller by the

Agency and to request the nature and substance of all information in its files on me at the time of my

request, including the sources of information, and the Agency, on Company’s behalf, will provide a

complete and accurate disclosure of the nature and scope of the investigation covered by any investigative

consumer report(s). The Agency will also disclose the recipients of any such reports on me which the

Agency has previously furnished within the two year period for employment requests, and one year for

other purposes preceding my request (California three years). I hereby consent to Company obtaining the

above information from the Agency. I understand that I can dispute, at any time, any information that is

inaccurate in any type of report with the Agency. I may view the Agency’s privacy policy at their

Applicant Safe, currently located at 428 Clifton Ave., Suite 166, Lakewood, NJ 08701,

732-942-1331