DSI INVESTIGATIONS
    222 S. EASTON ROAD
    GLENSIDE, PA 19038
    OFFICE: 215-576-7336   FAX: 215-576-0680

RELEASE OF LIABILITY

In connection with my application for employment with: ____________________________________________         

I hereby authorize all  corporations, companies, educational institutions,  individuals,  law enforcement  agencies,  present and former employers to release any and all information that they may have about me and further do release them from any liability and responsibility from  doing so. I authorize the procurement of an  investigative consumer report and understand that such  report may  contain information of my  background, mode of living, character and  personal reputation.

This authorization, in original or copy form, shall be valid for this and any  future or subsequent investigations that may be requested.

Please Print:

_________________________

_________________________

__________________________

First Name

Middle

Last

_________________________

_________________________

__________________________

Date of Birth (MM/DD/YY)

Social Security Number

Maiden or other name

_________________________________________________________

Address (Including Apartment #)

__________________________

_________________________

__________________________

City

State

Zip

_________________________________________________________

Previous Address

__________________________

__________________________

__________________________

City

State

Zip

____________________________________________

__________________________________

Driver's License Nbr.

State

____________________________________________________

__________________________

Signature

Date

___________________________________________________

__________________________

Witness

Date

(Rev. 10/98)

PRINT THIS FORM and forward to DSI Investigations, 222 S. Easton Road, Glennside, PA 19038 along with the subject's application and indicate what searches you want conducted. Fax: 215-576-0680