Disclosure of Intent to Obtain Consumer Report and/or Investigative Consumer Report for Employment Purposes

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1 Disclosure of Intent to Obtain Consumer Report and/or Investigative Consumer Report for Employment Purposes By this document and pursuant to the Fair Credit Reporting Act (FCRA), 4-County Electric Power Association discloses to you that a consumer report and/or an investigative consumer report may be obtained for employment purposes as part of the pre-employment background investigation and at any time during your employment with 4-County Electric Power Association. A consumer report is any communication of information from a consumer reporting agency that bears on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or collected for the purpose of establishing your eligibility for employment or continued employment. Such reports may include employment and education verifications, credit reports, criminal records, driving records, drug testing results, among other resources. An investigative consumer report is a special type of consumer report that includes information regarding your character, general reputation, personal characteristics and mode of living discerned through personal interviews with neighbors, friends, associates or others with whom you are acquainted. Vericon Resources, Inc. (VRI) or another consumer reporting agency, will obtain the consumer and/or investigative consumer reports for 4-County Electric Power Association. VRI is a consumer reporting agency with the following contact information: 3295 River Exchange Dr. Suite 405 Norcross, GA Phone: VRI s privacy policy may be found at You have certain rights under the FCRA, which are described in the attached Summary of Rights, as well as under analogous applicable state law. Should 4-County Electric Power Association request an investigative consumer report about you, you have the right to request a complete and accurate disclosure of the nature and scope of the investigation. The demand must be made in writing and within a reasonable period of time after you have received this disclosure. Please sign below to signify your receipt and understanding of the foregoing FCRA disclosure. You acknowledge and agree that your electronic signature below is legally binding and equivalent to your handwritten signature. Signed: Date: Revision Date: 10/06/2015

2 Written Authorization to Obtain a Consumer Report or Investigative Consumer Report I authorize 4-County Electric Power Association to obtain a consumer report and/or investigative consumer report in connection with my application for employment and at any subsequent time during my employment with 4-County Electric Power Association. I agree 4-County Electric Power Association may obtain such reports from Vericon Resources, Inc. ( VRI ) or another consumer reporting agency. I understand that such reports may include information from records (such as criminal, credit, driving, education, drug testing results, and other records) and/or written or verbal information from personal interviews with those who are acquainted with me or who may have knowledge about my character, general reputation, personal characteristics, and mode of living. VRI is a consumer reporting agency located at 3295 River Exchange Dr. Suite 405 Norcross, GA and can be reached at VRI s privacy policy may be found at To the extent 4-County Electric Power Association procures an investigative consumer report on me, I understand that I am entitled to request a complete and accurate disclosure of the nature and scope of any such investigative consumer report. I acknowledge that I have carefully read and fully understand this authorization, as well as the previous disclosures of my rights. I further acknowledge that I have received a Summary of Rights under 15 U.S.C et seq. I certify that the information provided on this authorization form is true and correct. Signed: Date: Last Name, First Name, Middle Name (PLEASE PRINT LEGIBLY) Position Applying For Applicant s Signature and Date (required) Date: Driver s License Number & State Lic # State *Responses to the * questions are optional and voluntary, for Identification only. Social Security Number *Date of Birth Phone Number Former Names and Time Frames Current Address City/State/Zip County Dates (Mo/Yr Mo/Yr) Previous Addresses (Past 7 Years) If you would like a free copy of the consumer report prepared for you, please call If you are applying for employment in the state of California, Minnesota or Oklahoma, would you like a copy of the consumer report prepared for you? (CA Civil Code Section ) Yes No Revision Date: 10/06/2015

3 Additional State Law Disclosures If you are a Massachusetts, New Jersey Minnesota, New York, Washington State, or California applicant or employee, please note the following (as applicable): Massachusetts and New Jersey You have the right, upon request, to receive a copy of any investigative consumer report 4 County Electric Power Association obtains about you. Minnesota Upon written request, you have the right to obtain from Vericon Resources, Inc. a complete and accurate written disclosure of the nature and scope of the consumer reports about you requested by 4 County Electric Power Association. You also have the right, upon request, to receive a copy of the consumer report that 4 County Electric Power Association obtains about you. If you would like to obtain a copy of this report, please select the option on your authorization form to request a copy. New York You have the right, upon request, to be informed of whether or not a consumer report or investigative consumer report was requested from a consumer reporting agency. If one was requested, you will be provided with the name and address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of any investigative consumer report by contacting that agency. Please refer to the below text of New York Correction Law, Article 23-A: ARTICLE 23-A LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY CONVICTED OF ONE OR MORE CRIMINAL OFFENSES 750. Definitions. For the purposes of this article, the following terms shall have the following meanings: (1) "Public agency" means the state or any local subdivision thereof, or any state or local department, agency, board or commission. (2) "Private employer" means any person, company, corporation, labor organization or association which employs ten or more persons. (3) "Direct relationship" means that the nature of criminal conduct for which the person was convicted has a direct bearing on his fitness or ability to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in question. (4) "License" means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions or instrumentalities as a condition for the lawful practice of any occupation, employment,

4 trade, vocation, business, or profession. Provided, however, that "license" shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire any explosive, pistol, handgun, rifle, shotgun, or other firearm. (5) "Employment" means any occupation, vocation or employment, or any form of vocational or educational training. Provided, however, that "employment" shall not, for the purposes of this article, include membership in any law enforcement agency Applicability. The provisions of this article shall apply to any application by any person for a license or employment at any public or private employer, who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any license or employment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdiction preceded such employment or granting of a license, except where a mandatory forfeiture, disability or bar to employment is imposed by law, and has not been removed by an executive pardon, certificate of relief from disabilities or certificate of good conduct. Nothing in this article shall be construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with an application for employment made by a prospective employee or previously made by a current employee Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited. No application for any license or employment, and no employment or license held by an individual, to which the provisions of this article are applicable, shall be denied or acted upon adversely by reason of the individual's having been previously convicted of one or more criminal offenses, or by reason of a finding of lack of "good moral character" when such finding is based upon the fact that the individual has previously been convicted of one or more criminal offenses, unless: (1) there is a direct relationship between one or more of the previous criminal offenses and the specific license or employment sought or held by the individual; or (2) the issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk to property or to the safety or welfare of specific individuals or the general public Factors to be considered concerning a previous criminal conviction; presumption. 1. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall consider the following factors: (a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons previously convicted of one or more criminal offenses. (b) The specific duties and responsibilities necessarily related to the license or employment sought or held by the person. (c) The bearing, if any, the criminal offense or offenses for which the person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities. (d) The time which has elapsed since the occurrence of the criminal offense or offenses. (e) The age of the person at the time of occurrence of the criminal offense or offenses. (f) The seriousness of the offense or offenses. (g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct. (h) The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of specific individuals or the general public. 2. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein Written statement upon denial of license or employment. At the request of any person previously convicted of one or more criminal offenses who has been denied a license or employment, a public agency or private employer shall provide, within thirty days of a request, a written statement setting forth the reasons for such denial.

5 755. Enforcement. 1. In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to article seventy-eight of the civil practice law and rules. 2. In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights pursuant to the powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city commission on human rights. Washington State If 4 County Electric Power Association requests an investigative consumer report, you have the right, upon written request made within a reasonable period of time after your receipt of this disclosure, to receive a complete and accurate disclosure of the nature and scope of the investigation requested by 4 County Electric Power Association. For further information, please consult the written summary of your rights under the Washington Fair Credit Reporting Act below: A Summary of Your Rights Under the State of Washington Fair Credit Reporting Act The purpose of the Washington Fair Credit Reporting Act is to promote accurate credit data collection, maintenance, and reporting on the citizens of the state. Under the Act, you have a right: To have your name and address excluded from any list provided by a credit-reporting agency in connection with a credit transaction or direct solicitation that you do not initiate. You must notify the credit reporting agency in writing through the notification system maintained by the agency, and must include a statement that you do not consent to any use of consumer reports relating to you in connection with any transaction you did not initiate. To request a credit reporting agency to disclose all information in its file on you at the time of your request, including disclosure of the sources of the information. To the identification of each person or business which obtained your report for employment purposes during the two years prior to your request, and each person or business which obtained your report for any other purpose within six months prior to your request, including those inquiries in connection with a credit transaction you did not initiate. Identification will include the name of the person or trade name under which the person conducts business, and if you request, that person s business address. To receive credit file disclosures during normal business hours and on reasonable notice (1) in person, if you appear in person and furnish proper identification, (2) by telephone, if you make written request with proper identification and pay for any toll charges, or (3) by any other reasonable means available to the credit reporting agency and authorized by you. For in-person disclosure, you may be accompanied by one other person of your choosing, although you may be required to furnish written permission for your credit file to be discussed in the other person s presence. If a credit score is disclosed as part of your credit report, you will be provided an explanation of the meaning of the credit score. For questions or concerns regarding the State of Washington Fair Credit Reporting Act, please write to: Attorney General of the State of Washington 1125 Washington Street S.E. P.O. Box Olympia, WA or call (360) To notify the credit-reporting agency if you dispute the completeness or accuracy of any item or information in your credit report and to have disputed items reinvestigated without charge, and the current status of the disputed information recorded in your credit file within 30 business days from the date the credit reporting agency receives your dispute. You will be notified if the agency stops reinvestigating disputed information upon determining the dispute is frivolous or irrelevant, including failure on your part to provide sufficient information relative to the dispute. Such notice will be in writing within five business days after the determination that the

6 dispute is frivolous or irrelevant. To have the credit reporting agency review all information you submit which is relevant to the disputed information. To receive notification from the credit reporting agency when information you disputed is deleted from your credit file because it could not be verified, but is subsequently found to be complete and accurate and is reinserted into your credit file. To file a brief statement with the credit reporting agency setting forth the nature of your dispute, if the reinvestigation does not resolve the dispute or it is found to be frivolous or irrelevant. Your statement may be limited by the credit reporting agency, provided you receive help from the agency in writing a clear summary of the dispute. To request that the credit reporting agency, when a disputed item of information has been deleted or remains on file with a statement of dispute, provide notification to any person you designate who, within the past two years, received a copy of your consumer report for employment purposes, or who, within the past six months, received a copy of your consume report for any other purpose. To receive the results of the reinvestigation of the disputed information within five business days following completion of the reinvestigation. To request that the credit reporting agency provide you with a description of the procedure used to determine the accuracy and completeness of the information disputed, including the name, business address, and telephone number of the person or business contacted during the reinvestigation. To receive disclosure of the information in your credit file without charge, if requested within 60 days following your receipt of a notice denying you credit, employment, insurance, or other benefit, or notification from a debt collection agency stating that your credit may be or has been impaired. No charges will be imposed for any reinvestigation of disputed information, deletion of information found to be inaccurate, or for assisting you in filing your statement of dispute, for notifying persons who previously received your consumer report. If you have not been denied credit, employment, insurance, or other benefit, the credit reporting agency may charge a fee not exceeding $8.00 for disclosure and all subsequent handling as listed here. To receive, from a user of consumer reports (such as a credit), which has taken adverse action regarding you based on your credit report, (1) notice of the action taken, and (b) the name, address and telephone number of the credit reporting agency that furnished the report. Notice of adverse action must be in writing, except verbal notice may be given if the business is regulated by the Washington Utilities and Transportation Commission, or involves an application for the rental and leasing of residential real estate. To bring legal action against a credit reporting agency for failure to comply with its obligations under this law, if you do so within two years after the agency fails to comply (unless the credit reporting agency materially and willfully fails to comply, in which case you may file legal action anytime within two years after you learn the agency has done so. California In connection with your application for employment and at any time during your employment, 4 County Electric Power Association may obtain investigative consumer reports regarding you for employment purposes. Such a report may include information as to your character, general reputation, personal characteristics, and mode of living. The investigative consumer reports will be obtained from the following investigative consumer reporting agency: Vericon Resources, Inc. (VRI), 3295 River Exchange Dr. Suite 405 Norcross, GA Phone: VRI s privacy policy may be found at 4 County Electric Power Association will ask VRI to investigate and report on the following: Your motor vehicle driving record to the extent such information may legally be obtained for employment purposes; Verification of your identity based on the social security number you have provided to us;

7 Your education record; Your employment history (to the extent authorized by you), consisting of information about your wages/salary, dates of employment, the reason for leaving, eligibility for rehire, and attendance/tardiness on jobs you have held; Drug testing results; Information about your character, general reputation, and personal characteristics obtained from employers for whom you have worked and your personal references; and Your criminal record for the past seven years to the extent such information may legally be obtained for employment purposes. You have the right to obtain a copy of the investigative consumer reports prepared about you. If you would like to obtain a copy of these reports, please select the option in your authorization to request copy. Below for your viewing is a summary of your rights under California Law, section : (a) An investigative consumer reporting agency shall supply files and information required under Section during normal business hours and on reasonable notice. (b) Files maintained on a consumer shall be made available for the consumer's visual inspection, as follows: (1) In person, if he appears in person and furnishes proper identification. A copy of his file shall also be available to the consumer for a fee not to exceed the actual costs of duplication services provided. (2) By certified mail, if he makes a written request, with proper identification, for copies to be sent to a specified addressee. Investigative consumer reporting agencies complying with requests for certified mailings under this section shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the investigative consumer reporting agencies. (3) A summary of all information contained in files on a consumer and required to be provided by Section shall be provided by telephone, if the consumer has made a written request, with proper identification for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to the consumer. (c) The term "proper identification" as used in subdivision (b) shall mean that information generally deemed sufficient to identify a person. Such information includes documents such as a valid driver's license, social security account number, military identification card, and credit cards. Only if the consumer is unable to reasonably identify himself with the information described above, may an investigative consumer reporting agency require additional information concerning the consumer's employment and personal or family history in order to verify his identity. (d) The investigative consumer reporting agency shall provide trained personnel to explain to the consumer any information furnished him pursuant to Section (e) The investigative consumer reporting agency shall provide a written explanation of any coded information contained in files maintained on a consumer. This written explanation shall be distributed whenever a file is provided to a consumer for visual inspection as required under Section (f) The consumer shall be permitted to be accompanied by one other person of his choosing, who shall furnish reasonable identification. An investigative consumer reporting agency may require the consumer to furnish a written statement granting permission to the consumer reporting agency to discuss the consumer's file in such person's presence.