I hereby authorize Informus acting as an agent for ___________________________________________ to receive any criminal history record information pertaining to me which may be in the files of any state or any local criminal justice agency.

To be completed by EMPLOYER:

Date of request:___________________________________________

Signature of requester:___________________________________________

Employer's Full Name:___________________________________________

Employer's Street Address:___________________________________________

Employer's City, State and Zip Code:___________________________________________

To be completed by EMPLOYEE:

Employee's Social Security Number:___________________________________________

Employee's Date of Birth:___________________________________________

Employee's Full Name:___________________________________________

Employee's Street Address:___________________________________________

Employee's City, State and Zip Code:___________________________________________

Signature of Employee:___________________________________________




Subscribed and sworn before me, in my presence, this ________ day of ____________________

19, ____, a Notary Public in and for the state of ______________________________________.


						     _______________________________________
						     (Signature of Notary Public)

My Notary Commission expires ________________, 19_____.






Informus Form-CR2