DISCLOSURE AND AUTHORIZATION [IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING]

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Rhoda Alexander
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1 DISCLOSURE AND AUTHORIZATION [IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING] DISCLOSURE REGARDING BACKGROUND INVESTIGATIONS LogistiCare Solutions, LLC ( the Company ) may obtain information about you from a third party consumer reporting agency for purposes of evaluating your application to provide services as an Independent Transportation Participant (ITP). Thus, you may be the subject of a consumer report and/or an investigative consumer report which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which may involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records (driving records), verification of your education or employment history, or other background checks. Credit history will only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying. You have the right, upon written request made within a reasonable time, to enquire whether a consumer report has been run about you, receive information about the nature and scope of any investigative consumer report(s), and request a copy of your report(s). Please be advised that the nature and scope of the most common forms of investigative consumer reports for applicants who wish to provide services as ITPs are criminal background checks and motor vehicle records. All background checks will be conducted by Occuscreen, LLC, 805 Broadway Street, Suite 215, Vancouver, WA 98660, (888) , The scope of this Disclosure is all-encompassing and your signature allows the Company to obtain from any outside organization all manner of consumer reports throughout the course of your provision of services as an ITP, to the extent permitted by law. I have read and understand this Disclosure Regarding Background Investigations and I agree that a facsimile (fax), electronic or photographic copy of this Disclosure shall be as valid as the original. Signature Printed Name Date Page 1 of 1 Disclosure and Authorization Form

2 ACKNOWLEDGEMENT AND AUTHORIZATION FOR BACKGROUND CHECK I acknowledge receipt of the separate documents entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize LogistiCare Solutions, LLC to obtain consumer reports and/or investigative consumer reports at any time after receipt of this Acknowledgement and Authorization and throughout my provision of services as an Independent Transportation Participant, if applicable. this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Occuscreen, LLC, 805 Broadway Street, Suite 215, Vancouver, WA 98660, (888) , and/or by LogistiCare Solutions, LLC. I agree that a facsimile (fax), electronic or photographic copy of this Authorization shall be as valid as the original. Signature Printed Name Date Page 1 of 2 Acknowledgement and Authorization of Background Check

3 In order to process your background check, please provide the following information. Include your exact legal name and any other name(s) you may have used in the last seven (7) years. Please print clearly in ink or type the following information: First Name: Middle Initial: Last Name: Social Security Number: Birth Date: Current Address: City: State: Zip: Driver s License #: State: Other Names Used (previous 7 years only): Please provide City and County information for your residence covering a period of seven (7) years, beginning with your most current address. City County State Zip Page 1 of 2 Acknowledgement and Authorization of Background Check

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$s:\library\volunteers\application, interview & training materials\volunteer application.docx$ 1 2 3 DISCLOSURE AND AUTHORIZATION [IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION] DISCLOSURE REGARDING BACKGROUND INVESTIGATION The City of Lincoln City may obtain information about