•••••• ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

Consumer Report Disclosure and

Authorization for Employees

I hereby acknowledge and understand that in connection with my employment relationship

and/or application for a position with Randstad North America, LP, its subsidiaries, affiliates,
business units and/or successors (collectively “the Company”), the Company may procure or
cause to be procured consumer reports which contain information about me. These consumer
reports may contain information such as, my credit history, criminal record, motor vehicle
record, driving record and/or motor vehicle accident record, which may be obtained from
governmental or private entities which maintain such records. The Company may obtain these
consumer reports directly, or it may obtain them through a consumer reporting agency.

I further acknowledge and understand that the Company may share and transfer information
reported on or learned from these consumer reports to its clients, for whom I wish to be
considered for temporary and/or permanent employment, assignment or placement.

I further acknowledge and understand that I have a right to request certain information from
any consumer reporting agency which provides a consumer report to the Company, and that
I have the right to dispute inaccurate information with the consumer reporting agency. Further,
if the Company takes an adverse action against me based in whole or in part upon a consumer
report provided by a consumer reporting agency, I will be informed of that fact, given a
summary of my rights under the Fair Credit Reporting Act, provided with a copy of the
consumer report, and given the name, address, and telephone number of the consumer
reporting agency that provided the consumer report.

I hereby authorize the Company to procure consumer reports including but not limited to
information about my credit history, criminal record, motor vehicle record, driving record, and
motor vehicle accident record, from any consumer reporting agency.

I hereby further authorize the Company to share and transfer information reported on or
learned from these consumer reports to its clients, for whom I wish to be considered for
temporary and/or permanent employment, assignment or placement.

This authorization shall remain on file with the Company throughout the duration of my
employment relationship with the Company (if any), and shall serve as ongoing authorization
for the Company to procure consumer reports at any time during my employment with the
Company (if any) and to share and transfer information reported on and learned from these
consumer reports to its clients, for whom I wish to be considered for temporary and/or non-
temporary employment, assignment or placement.

Name (please print)

Date of birth (will be used for identification purposes only)

Gender
male
female

Social security number (will be used for identification purposes only)

Driver’s license state of issue (will be used for identification purposes only)

Driver’s license number

Street address

City/state/zip

Print all former names used

Signature Date

CRDA-0803