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526 C Country Club Lane
Hopkinsville, Kentucky 42240
P.O. Box 20543
Clarksville, Tennessee

(931) 542-6944
Mon - Fri: 8:00 AM - 5:30 PM
Sat: 10:00 AM - 3:00PM
Sun: Closed

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*****SEE ATTACHED REFERENCE SHEET*****
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Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature

Date

1-On-1 Care Matters, LLC Employee Reference Check

Employee

Personal References:

Name:

Contact number:

Years known:

Agency use only:

Date Personal reference checks completed

Agency Representative:

Background Investigation Requested 1 ON 1 Care By: Matters 249 Moncrest Drive Clarksville, Tennessee 37042

Background Investigation Fowlers' Compiled By: Profile Links, Inc. P. O. Box 291043 Nashville, TN 37229-1043

1-On-1 Care Matters

DISCLOSURE AND AUTHORIZATION FORM

BACKGROUND INVESTIGATION QUESTIONNAIRE:

Name

Last First Middle Name

Address

Street City State ZIP / Postal Code

Social Security Number:

Telephone Number:

Other Name (s):

(Used Within the Last 7YRS. E.g. Maiden, Other Married Names)

Year of Name Change

Driver's License Number:

State

Date of Birth:

Name on Driver's License:

Previous Residential Addresses (Previous 7 years):

Address

Street City State Years Resided

Address

Street City State Years Resided

Address

Street City State Years Resided

Have you been convicted of any criminal offense, either misdemeanor or felony, other than minor traffic violations in the last 7 years?

Are you currently charged or under investigation for any violation of the law other than minor traffic violations?

DISCLOSURE [IMPORTANT AND AUTHORIZATION
[IMPORTANT AND AUTHORIZATION - PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION]
DISCLOSURE REGARDING BACKGROUND INVESTIGATION

1-ON-1 Care Matters may obtain information about you from a consumer reporting agency for Employment purposes. Thus, you may be the subject of a "consumer report" and/or an "investigative consumer report" which may include Information about your character, general reputation, personal characteristics, and/or mode of living and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records ("driving records"), verification of your education or employment history, or other background checks. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants as a tenant is an investigation into your education and/or employment history conducted by Fowlers' Profile Links, Inc., PO Box 291043, Nashville, TN, 37229, 1-866-887-7581 or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing 1-ON-1 Care Matters to obtain from any outside organization all manners of consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

ACKNOWLEDGMENT AND AUTHORIZATION I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" by the Company at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Fowlers' Profile Links, Inc., PO Box 291043, Nashville, TN, 37229, 1-866-887-7581 another outside organization acting on behalf of 1-ON-1 Care Matters, and/or 1-ON-1 Care Matters itself. I agree that a facsimile ("fax"), electronic or photographic copy of this Authorization shall be as valid as the original.
NOTICE: Fowlers' Profile Links, Inc. requests your Date of Birth solely for the purpose of verifying certain records that may be produced in connection with Fowlers' Profile Links, Inc. background investigation. It is the pollcy of this facility to provide equal opportunity to persons regardless of race, religion, age, gender, disability or any other classification in accordance with federal, state and local statutes, regulations and ordinances.

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Date