In connection with my application for employment (including contract for services) with Select Medical Staffing, I understand that investigative background inquires are to be made concerning my consumer credit, criminal convictions, motor vehicle records, education, and other reports. These reports will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment from previous employers. Further, I understand that you will be requesting information from various Federal, State, and other agencies that maintain records concerning my past activities relating to my driving, credit, criminal, civil, and other experiences, as well as claims involving me in the files of insurance companies.

I acknowledge that I have been counseled that a person or entity may not procure or cause to be prepared an investigative consumer report on any consumer unless it is clearly and accurately disclosed to the consumer, that an investigative consumer report — including all applicable information as to his or her character, general reputation, personal characteristics, mode of living — may be made. If you are denied employment because of the consumer investigation, it is your right under the Fair Credit Reporting Act (Law 91-508) SS 606 to have the name of the agency or agencies from whom information concerning you was obtained. You are also entitled to receive free copies of the information supplied to those agencies within sixty days upon written request. You have the right to directly dispute with the consumer-reporting agency the accuracy and completeness of any information furnished by that agency.

I authorize without reservation, any party or agency contacted by this employer to furnish the above-mentioned information.

I release Select Medical Staffing, Credential Check, and any other person and/or agencies from any damage and/or liable acts that may result from obtaining the above information.

The above information is used solely for employment verifications, credit inquires, and criminal history checks. Falsifying any information on this release form will constitute grounds for immediate dismissal or declining any pending job offers.

Signed:*   Date:*