Certificate Request Form
DISCLOSURE AND AUTHORIZATION TO PROCURE A CONSUMER REPORT FOR EMPLOYMENT PURPOSES
The undersigned hereby authorizes “Employer Name” or its insurance agent, Leugers Insurance Agency, Inc., or its assigns to obtain copies of consumer reports, including a motor vehicle report, pertaining to me for employment purposes, and for use in rating and/or underwriting insurance for which the above named employer may apply, and any renewal thereof. I understand that in obtaining such consumer reports, a consumer reporting agency may be used and I do hereby authorize such use.
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