Release of Liability

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