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2) Fill Out Information
3) Sign The Bottom
4) Fax To 888-894-2133

Release and Applicant Information Form

TR Information Services P.O. Box 780254 Orland FL 32878 Ph: 800-894-9141 Fax: 407-306-0277

Requestor Information:

Contact Person: ________________________ Company__________________________

Contact Phone: ______________________ Contact Fax: _______________________

E-Mail_____________________________________

Applicant/Subject Information:

Name: ______________________________________________ Home Phone: ______________

Please Print All Requested Information as it appears on your Drivng License Card

Current Address: _____________________________________ City: ____________ ST: _____ Zip:______

Sex: _____ Date of Birth: ___________________

Drivers License Number: ______________________________________ State: __________

I understand and agree that: The information supplied, was submitted by myself, and all information is true and correct, to the best of my knowledge. I understand that false or misleading information given in my application and/or interview(s) will be considered as cause for possible dismissal and/or discharge. I also understand that I am to abide by all rules and regulations of the company.

The company has my authorization to thoroughly investigate my work and personal history. I understand that the information supplied by me, regarding my: Employment History, Education (including an authorization to release transcripts), Credit History, Criminal History, Medical and Professional Licensing, Motor Vehicle Record(s), Residence History, and References, will be utilized as part of the processing procedures. A background check will be conducted to verify the veracity of the information submitted and will be utilized to develop information concerning my character, general reputation, personal characteristics, and mode of living. I will hold no person liable for giving or receiving information in this investigation. I hereby authorize

TR Information Services an agent of ___________________________________________________ (company name)
may be asked to make a thorough check of my credit history, driving history, criminal history , past employment, education, and activities. I release from liability all persons, companies, and corporations supplying that information. I release and indemnify

In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.

I release TR Information Services against any liability that might result from making such background checks. A copy of this form is as valid as the original.

Driver's Signature: X _____________________________________ Date: __________