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Title: Microsoft Word - 01 - PayGo Distributors-Background Authorization.doc
Author: DCB

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Authorization to Obtain Consumer Reports
First Name:________________________ Middle Name:
Last Name:_______________________
SS #: ________________________

Date of Birth:__________________

Street Address:________________________________________________
City _________________________

State: ________ Zip:____________

Prior Address:

State_________ Zip __________

Driver’s License # ____________________________ State___________
I authorize PAYGO Distributors to conduct a background check on me. I
understand that in connection with this background check, consumer reports may
be obtained. I understand that such reports may include, without limitation, public
record information concerning my driving record, and criminal records from
federal, state, local and other agencies, which maintain such records. I understand
that I may request a copy of my background check report.
I hereby, authorize PAYGO Distributors to procure such consumer report(s). This
authorization shall remain on file and shall serve as ongoing authorization for
PAYGO Distributors to procure consumer reports at any time.

Applicant Signature___________________________________ Date______________

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