AUTHORIZATION FOR RELEASE OF CONSUMER INFORMATION

							                                                                     AUTHORIZATION FOR RELEASE OF
                                                                           CONSUMER INFORMATION
                                                                            [EMPLOYMENT PURPOSE]
                                      TO BE COMPLETED BY APPLICANT/ASSOCIATE
                                              (PLEASE PRINT LEGIBLY OR TYPE)
  NAME:
               LAST NAME                                                                FIRST NAME                                              M.I.

  DATE OF BIRTH:
                      MONTH                              DAY              YEAR          SOCIAL SECURITY NUMBER

                                                                                        GENDER (CHECK ONE):       MALE        FEMALE        UNKNOWN
  DRIVER’S LICENSE NUMBER                               STATE

  ADDRESS:     *
                   STREET ADDRESS                                                    CITY                                      STATE         ZIPCODE

  *This is your Previous Out of State Address
 RACE (CHECK ONE):         ASIAN                                    AMERICAN INDIAN / ALASKAN                                    BLACK

                           WHITE                                    UNKNOWN

  Please note: persons of Hispanic or Latin nationality should check “Unknown”



                                   APPLICANT / ASSOCIATE SIGNATURE                                                        DATE


                                                       Applicant Authorization
  1.   I certify that the information provided above is true and complete. I understand that false or misleading information given in on this
       form will render this form void. Without reservation, I authorize Wheaton Franciscan Healthcare or any party or agency conta cted
       by Wheaton Franciscan Healthcare to procure my consumer report and/or to obtain or furnish information concerning my c riminal
       history. I further authorize the Illinois State Police to release criminal background information as a part of the criminal background
       investigation.
  2.   Under provisions of the Fair Credit Reporting Act, certain information, when used for employment purposes, is considered to be a
       consumer report. This information includes, but is not limited to, public record information (criminal history, civil litigation, etc.), driving
       records, consumer credit history, education records, and employment records. If an adverse employment decision is made due, in
       whole or in part, to information received as a result of these inquiries, I will be provided with a copy of the consumer report and a
       summary of my rights under the Fair Credit Reporting Act.

  PRINT FULL NAME:


  SOCIAL SECURITY NUMBER:      *                                                            DATE OF BIRTH:

  SIGNATURE:


  *This information is requested by VERIFY solely for purposes of insuring accurate retrieval of records.

                                    COMPLETED BY EMPLOYER (PLEASE PRINT LEGIBLY OR TYPE)
  COMPANY/ORGANIZATION               WHEATON FRANCISCAN HEALTHCARE

  MAILING ADDRESS:                   400 W. RIVER WOODS PARKWAY, GLENDALE, WI 53212

  CONTACT PERSON                     HUMAN RESOURCES

  TELEPHONE NUMBER:                  800-914-6601                                             FAX NUMBER:      414-465-3401




HR: 09.10.10