Release of Liability and Consent Form

I am aware that any omission, falsification, misstatement, or
misrepresentation on my application may disqualify me for
employment or contract consideration, and if I am hired/contracted,
that may be grounds for termination at a later date.

I understand that any information that I provide may be verified
as allowed by law. I authorize the procurement of a credit
report. I also authorize all persons and entities (including but
not limited to: former employers and supervisors; businesses;
corporations; credit reporting agencies; law enforcement agenices,
including the State of Georgia; government agencies; educational
institutions; and all military services) to release all verbal
and all written information regarding my ability and fitness for
consideration for employment/contract.

I hereby authorize Interstate Background Research, Inc. to receive 
any criminal history record pertaining to me found in the files of 
any law enforcement or criminal justice agency.

I realize that public record information may not be 100%
accurate, and that I may be required to submit a fingerprint card
for positive identification.

I release each individual and company from all liability, and from
all responsibility for providing said information and/or records.
 
This request/release is valid for one (1)year from this date hereon.
		
              ____________________________________________
              Your Full name, typed or printed

              ____________________________________________
              Your Address

              ____________________________________________
              Your City               State       ZIP Code 

              _______   __________   ___/___/______
              *Gender   *Race        *Date of Birth
                   
              _______/_____/________
              Social Security Number
                
              ___________________________________________
              Your Signature

                              THANK YOU

* May be deemed necessary to conduct a thorough criminal record
  search, in accordance with the "Code of Federal Regualtions."
  Equal Employment Opportunity Commission Code 1625.5

The request for your date of birth does not indicate discrimination
and the date request in itself is not a violation of the, "Age
Discrimination Act." Your date of birth is requested for a permissable
purpose and has been ruled a critical identifier for criminal and
driving history information. Certain states will not conduct a
criminal search without the date of birth. 










Please mail or FAX to:  IBRInc
                        Post Office Box 817
                        New Port Richey, Florida   34656-0817
                        FAX (727)848-7340  

form  2fr1- release of liability   rev 10/04/1999