Fair Credit Reporting Act

Mid-Cities Medical:

• when considering your application for employment;
• when deciding whether to offer you employment;
• when deciding whether to continue your employment (if you are hired); and
• when making other employment related decisions directly affecting you,

may wish to obtain and use a “consumer report” from a “consumer reporting agency.” These terms are defined in the Fair Credit Reporting Act (“FCRA”), which applies to you. As an applicant for employment or employee of Mid-Cities Medical, you are a “consumer” with rights under the FCRA.

A “consumer reporting agency” is a person or business that, for monetary fees, dues or on a cooperative nonprofit basis, regularly assembles or evaluates consumer credit information or other information on consumers for the purpose of furnishing “consumer reports” to others, such as Mid-Cities Medical.

A “consumer report” is any written, oral, other communication of any information by a “consumer reporting agency” bearing on a consumer’s credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics or mode of living which is used or collected for the purpose of serving as a factor in establishing the consumer’s eligibility for employment purposes.

An “investigative consumer report” is a consumer report in which the information about your character, general reputation, personal characteristics and mode of living is obtained in whole or in part through personal interviews with persons who may have knowledge concerning such information.

If Mid-Cities Medical obtains a “consumer report” about you, and if Mid-Cities Medical considers any information in the “consumer report” when making an employment related decision that directly and adversely affects you, you will be provided with a copy of the “consumer report” before the decision is finalized. You also may contact the Federal Trade Commission about your rights under the FCRA as “consumer” with regard to “consumer reports” and “consumer reporting agencies.”

AUTHORIZATION AND RELEASE

I hereby certify that the information provided by me for the purpose of employment is true and complete to the best of my knowledge. As part of my request for employment, I voluntarily authorize all persons, businesses, current and former employers and supervisors, credit reporting agencies, educational institutions, law enforcement agencies, motor vehicle departments and city, state, county and federal courts to release information they may have about me to Mid-Cities Medical. If I am employed by Mid-Cities Medical, this permission shall remain in effect as long as I am an employee.

Also, I request that a photocopy or facsimile of this Authorization be treated as though it were the original.

In accordance with the Fair Credit Reporting Act, if my employment is denied, based either wholly or partly on information contained in a consumer report or investigative consumer report from a consumer reporting agency, Mid-Cities Medical shall so advise me, and supply the name and address of the consumer reporting agency making the report.

I hereby authorize Mid-Cities Medical to obtain a consumer report and/or investigative consumer report regarding me in connection with: (1) my application for employment; and/or (2) if I am hired, my continued employment.

I ACKNOWLEDGE THAT I HAVE RECEIVED AND READ THIS “FAIR CREDIT REPORTING ACT DISCLOSURE, AUTHORIZATION AND RELEASE FORM.”

I HAVE ALSO RECEIVED A COPY OF “A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT.”