GEORGIA DEPARTMENT OF NATURAL RESOURCES

Consent for Background and Credit Check for P-Card

I understand that the Department of Natural Resources shall conduct background and credit checks thoroughly and within the confines of all applicable state and federal laws.

I hereby release DNR, its employees and agents, from all claims or liabilities that might arise from the inquiry into or disclosure of such information, including claims under federal, state, or local civil rights law and any claims for defamation or invasion of privacy.

I hereby give voluntary consent and authorization to DNR or its authorized representative bearing this release or copy thereof to perform periodic background checks for the duration of my employment with this department for the purpose of obtaining reports for employment purposes, including:

·  Criminal History

·  Credit History and Reports, Judgements and Bankruptcy Reports

This authorization is given freely and voluntarily without duress or coercion and constitutes a written instruction under the Fair Credit Report Act.

I understand that, pursuant to the federal Fair Credit Reporting Act, if any adverse action is to be taken based upon the consumer report, a copy of the report and a summary of the consumer’s rights will be provided to me.

I authorize all persons who may have information relevant to this research to disclose such information to DNR, or its agents, and I hereby release all persons from liability on account of true and accurate disclosure. I hereby further authorize that a photocopy to facsimile of this authorization can be considered as valid as the original. Should there be any questions as to the validity of this release, you may contact me as indicated below:

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Printed Name (First, Middle, Last, Maiden) Signature Date

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Address (Street) City, State, Zip Code

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Social Security Number Date of Birth Sex/Race Telephone Number

If any additional information relative to change of name or use of an assumed name or nickname is necessary to enable a check on your background, please explain below:

Updated 04/11/17