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FAIR CREDIT RELEASE Disclosure and Authorization Form


                             United States Department of Agriculture
                             Natural Resources Conservation Service

                           FAIR CREDIT RELEASE
                      Disclosure and Authorization Form
In accordance with the Federal Fair Credit Reporting Act (Public Law 91-508, 15, U.S.C.
Section 1681 ET SEQ., 604-615), all federal provisions and regulations, a credit report may be
requested and obtained for employment and other exclusive purposes.

Compliance by the employer with all regulations and statutes of the Fair Credit Reporting Act is
required in order to obtain information. Information is requested for the exclusive use of the
employer and will not be used for any other purpose than employment.

By signing this release, you certify that all information provided below and on your resume is
correct to the best of your knowledge. Any false statements provided in this form and your
resume will be considered just cause for the termination of employment at any time. Further,
you agree that a copy or facsimile of this authorization shall be as valid as the original. In
addition, you release and discharge NRCS and all of its agents, any expenses, losses, damages,
and liabilities for the investigative process.

If your credit report is the basis for any adverse action taken against you, the agency will provide
the name and contact information of the credit reporting agency (CRA) that provided the report.
You must contact the CRA within 60 days of receiving notice of the adverse action. The CRA
must provide you a copy of your credit report (at no cost).

Applicant’s Name: ___________________________________________________________
     (Please Print)            First                    M.I.                Last

Social Security Number: _________ - _________ - _________

Current Address: ___________________________________________________
                                              Street Address

                               City             State                Zip

Signature: __________________________________________ Date: _____ mm/ _____ dd/ _____yy

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