Medicare Trans LLC

I certify that the above information is true and accurate to the best of my ability. I authorize investigation of all statements contained in this application; I understand that the misrepresentation or omission of facts called for is cause for dismissal. I hereby give Medicare Trans, LLC, permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the company from any liability as a result of such contact.

Medicare Trans, LLC, is an equal employment opportunity employer. The company adheres to a policy of making all decisions without regard to race, color, gender, national origin, religion, marital status, veteran/uniformed services status, age, disability, or other protected class status.

In connection with my ongoing employment or my application for employment, should I have or secure a position with Medicare Trans LLC, I understand that a motor vehicle record, which contains public record information, may be requested. I further understand that such report(s) will contain personal information and public record information concerning my driving record from federal, state, and other agencies that maintain such records, as well as independent services that provide driving record information.

I authorize, without reservation, any party or agency contacted to furnish the above-mentioned information to The Arizona Group or its agent.

I hereby authorize procurement of my motor vehicle report. If hired, this authorization shall remain on file and shall serve as ongoing authorization for you to procure such reports at any time during my employment. Medicare Trans LLC's commercial auto insurer and agent will also use this information in conjunction with loss control and safety review efforts.

Disclosure Regarding Background Investigation

MEDICARE TRANS, LLC ("the Company") may obtain information about you for employment purposes from a third party consumer reporting agency. 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 can 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 request whether a consumer report has been run about you, and disclosure of the nature and scope of any investigative consumer report and to request a copy of your report. The most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by Occuscreen, LLC, 805 Broadway Street, Suite 215, Vancouver, WA 98660, (888) 833-5304, www.occuscreen.com, or another outside organization. The scope of this notice and authorization is all-encompassing, allowing the Company to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law.

Summary of Your Rights Under the Fair Credit Reporting Act (FCRA)

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. You have the right to know what is in your file, to dispute incomplete or inaccurate information, and to limit access to your file to those with a valid need. Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information and generally may not report outdated negative information. You must give your consent for reports to be provided to employers (written consent is generally not required in the trucking industry). For the full summary of your rights, contact the Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20006, or visit consumerfinance.gov/learnmore.

I acknowledge receipt of the 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 the obtaining of "consumer reports" and/or "investigative consumer reports" by MEDICARE TRANS, LLC at any time after receipt of this authorization and throughout my employment, if applicable. To 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) 833-5304, www.occuscreen.com, another outside organization acting on behalf of the Company, and/or the Company itself. I agree that a facsimile ("fax"), electronic or photographic copy of this Authorization shall be as valid as the original.