LSJE, Inc.

LSJE, Inc. 6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 [email protected] Tel: 340-775-8100 Fax: 340-775-8108 Notification/Release of Information Form The Purpose of this form is to notify you that consumer report will be conducting on you in the course of consideration for employment with Last Name: IRE- I' 7 First Name: ELM g Social Security: Driver's License it State Issued: p ease a tac a copy) Passport t4 (please attach a copy) Date of Birth: Place of Birth: Middle In: City: State Zip: In connection with this request I, eil44.4.pc re e-7-- 7 - authorize all corporations, former employers, credit agencies, educational institutions, law informant agencies, city, state county, federal courts and military services to release information about all my background including, but not limited to information about all employment, education, consumer, credit history, driving record, criminal record and general public history to the person or company with which this form has been filed or their agent. This releases the aforesaid parties from any liability and responsibility for collection of the above information. / Applicants Signature 7 ..4.,.2%-• Date ,C),I -O7-20/ EFTA00613372