(This form authorizes the organization to obtain background information and must be completed by the applicant.  The organization must keep this completed form on file for at least two years after requesting a background check.)

I, the undersigned applicant, authorize Bread of Life Missions thorugh its independent contractor, LexisNexis, to procure background information about me.  This report may include my driving history, including any traffic citations, a social security number verification, present and former addresses, criminal and civil history/records, and the state sex offender records.

I understand that I am entitled to a complete copy of any background information report of which I am the subject upon my request to Bread of Life Missions, if such is made within a reasonable time from the date it was produced.  I also understand that I may receive a written summary of my rights under the Fair Credit Reporting Act.