Consumer Reports

NOTIFICATION AND AUTHORIZATION
FOR PROCUREMENT OF CONSUMER REPORTS

The purpose of this release is to allow SMP Industries, INC. (referred to as "Company"), Application Researchers, LLC, or their assigns, to obtain background information which may include any lawful investigation of my educational background and criminal, driving, credit, and employment histories, as well as any other verification's deemed appropriate, while maintaining compliance with all governmental laws.

In accordance with the Fair Credit Reporting Act, 15 U.S.C. 1681, et seq, I am aware I have the right to make a written request of Application Researchers, LLC, Post Office Box 11, Chattanooga, Tennessee 37401-0011, (800) 865-5727, to obtain additional information regarding the nature and scope of the background check, as well as receive a written summary of my rights under the Fair Credit Reporting Act.

If the Company considers the background checks unfavorable, I agree that the Company may deny me the assignment or discharge me from employment. I release the Company, its officers, agents, and employees from all liability resulting from the collection, use, or disclosure of the information obtained during the above investigation. I authorize ongoing procurement of the above-referenced reports at any time, either during the time of my application for employment is being considered or throughout the duration of my assignment in the event that I am a current Company employee.

I certify that the information set forth below is complete and true. I have read this release and consent, understand its terms, realize its significance, and sign it voluntarily.

I am willingly providing the following information necessary for the above investigation and understand that this information is being used for verification purposes only.

Please Print

NAME-FIRST MIDDLE: LAST:

LIST ANY OTHER NAMES USED (nicknames, maiden/married last names):

DATE OF BIRTH: SSN#

DRIVER'S LICENSE STATE: State: NUMBER:

LIST ALL CITIES/STATES RESIDED AND WORKED WITHIN THE LAST FIVE YEARS:

1. 2.
3. 4.
5. 6.

SIGNATURE (USE MOUSE OR TOUCHSCREEN):

DATE:

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