Greystone

GREYSTONE

NOTIFICATION AND DISCLOSURE REGARDING CONSUMER REPORT

Greystone hereby notifies you that it may obtain, for employment purposes, a consumer report related to you from a consumer reporting agency. This may include or consist entirely of a criminal background check, civil records check, a driving record and/or a credit check. Any such report may contain information bearing upon your credit, character, reputation, personal characteristic, or mode of living.

This disclosure is made in accordance with the Fair Credit Reporting Act and any pertinent state law.

In the event of any adverse actions based on a consumer report, prior to the taking of that adverse action we will provide you with a copy of the report.

AUTHORIZATION TO PROCURE CONSUMER REPORT

By your signature below, you acknowledge that you understand and voluntarily authorize Greystone to procure a consumer report from a consumer reporting agency and agree to indemnify and hold harmless the consumer reporting agency against any and all liability, cost and expenses, including attorney's fees, occasioned by claims or suits for loss or damages arising out of the reasonable and lawful acts in connection with this service.

Current Name(Required)

First Middle Last

Former Name 1

First Middle Last

Maiden Name, Former Married Name, Other Name Used

Former Name 2

First Middle Last

Maiden Name, Former Married Name, Other Name Used

Address(Required)

Street Address City State ZIP Code

Social Security Number(Required)

Date of Birth(Required)

Driver's License(Required)

State(Required)

Have you lived at present residence less than seven years?(Required)

Yes
No

Previous Address (1)(Required)

Street Address City State ZIP Code

Previous Address (2)

Street Address City State ZIP Code

Property Name Applying For

I hereby release INTERPROBE, INC., and its officers, directors, employees and agents, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family or associates, because of compliance with this authorization.

Signature