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Introduction About HomeTown Lenders HomeTown Lenders is a debt-free, Full Eagle lender who believes in treating all employees and customers fairly. Since our inception in March of 2000, we have grown to be one of the leading mortgage lenders in the nation. Our corporate philosophy is: “We Exist To Serve!” Our growth formula has always been to: 1) Hire the best. 2) Retain the best. 3) Remember Who got us there. Our company exists for a greater cause and that is to “Continually become more like Christ in all that we do”. Out of this thought we established a 501c3 called Mission Firefly (www.missonfirefly.org). We have been able to accomplish this by maintaining an environment where employees feel supported and appreciated. Our main goal is to help every individual reach their fullest potential, and to provide them with the best originating platform in the industry. We realize that our continued growth will be determined by our ability to adapt to changing market conditions within our industry and we understand that we must continue to maintain an environment where loan officers and branch managers can maximize their income potential. We are a family business and we operate from a shared conviction that our people’s success is our responsibility. We appreciate that there is a family behind each of our employees and that each family is our responsibility too. We take pride in being the best in the business, and being honest and fair in every facet of our operation. We enjoy the small company agility and atmosphere while we are blessed with the power of a larger company. Those we serve are our responsibility and our mission is to support them & empower them. Our people come first and foremost – Our people are HomeTown Lenders. Sincerely, ERIC TISHAW Chief Executive Officer Hometown Lenders (256) 509-1186 [email protected]

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Page 1: Hometown Lenders

Introduction

About HomeTown LendersHomeTown Lenders is a debt-free, Full Eagle lender who believes in treating all employees and customers fairly. Since our inception in March of 2000, we have grown to be one of the leading mortgage lenders in the nation. Our corporate philosophy is: “We Exist To Serve!”

Our growth formula has always been to:

1) Hire the best.2) Retain the best.3) Remember Who got us there. Our company exists for a greater cause and that is to “Continually

become more like Christ in all that we do”. Out of this thought we established a 501c3 called Mission Firefly (www.missonfirefly.org).

We have been able to accomplish this by maintaining an environment where employees feel supported and appreciated. Our main goal is to help every individual reach their fullest potential, and to provide them with the best originating platform in the industry.

We realize that our continued growth will be determined by our ability to adapt to changing market conditions within our industry and we understand that we must continue to maintain an environment where loan officers and branch managers can maximize their income potential.

We are a family business and we operate from a shared conviction that our people’s success is our responsibility. We appreciate that there is a family behind each of our employees and that each family is our responsibility too.

We take pride in being the best in the business, and being honest and fair in every facet of our operation. We enjoy the small company agility and atmosphere while we are blessed with the power of a larger company. Those we serve are our responsibility and our mission is to support them & empower them.

Our people come first and foremost – Our people are HomeTown Lenders.

Sincerely,

ERIC TISHAW Chief Executive OfficerHometown Lenders(256) [email protected]

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We’ve partnered up with the leading industry icons…

…to make sure you stay on the cutting edge!

Barry Habib and the MBS

HighwayCarl White Roberto Monaco

Frank Garay& Brian Stephens

HomeTown Lenders has been featured in:

Mortgage Marketing Animals

www.hometownbranch.com • 888-606-8066

Two Years in a Row!

We’re In The List!

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“A Better Home For Your Branch”Our program was designed to be ‘BETTER’.

Better people, better tools, & better products. We believe in long-term relationships with our partners and that’s what makes us better.

No matter who you compare us to, see for yourself why Hometown Lenders is “BETTER!”

We are currently looking for high-quality Originators, Branch Managers, and Regional Managers in AL, CO, FL, GA, KY, OH, SC, TN, TX, LA, NC, MS, MO & IN

Visit www.hometownbranch.com to read our testimonials!

CALL US TODAY AT

888-606-8066

We Help You Grow Your Branch and Skyrocket Your Income!

• 24 Hour Underwrites

• Our recruiters place producers in your branch!

• Get paid every week

• When you call, we answer!

• Marketing “Maps” that will TRIPLE your business!!

• Create, customize and optimize your branch’s compensation plan

• Industry leading branch support headed by a DE underwriter with a loan scenario help desk

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“I’ve been with Hometown Lenders since September 2002. I couldn’t imagine ever wanting to be anywhere else. The company is “big enough” to support me and my branches but “small enough” that my opinion matters. What Hometown does best is support the “small business owner” mentality that exists within most of its entrepreneurial Branch Managers. They even refer to us as “Partners” and it shows in everything they do. Whenever I wanted to open a branch and hire more MLOs, they put a recruiter on it and helped me staff a brand new office from scratch. They’ve done this over and over for five locations. They understand what it takes to grow business. They know how to market, they know how to recruit, and most importantly they know how to retain. Hometown believes their most valuable asset is their people and my 10+ career here is proof of that. Year over year, since 2002, my income has increased. Yes, that includes 2007, 2008, and 2009. I made more money every, single year. You couldn’t ask for a better partner in the mortgage business than Hometown Lenders.”

Conrad T. – Huntsville, AL

“Eric, I wanted to say thank you for bringing us into the Hometown Lenders Family. We thought we were very successful before we came to Hometown and we were. However, by allowing you all to help us tweak what we were already doing, and adding a marketing campaign that is proven, we have grown our business every month since joining. We are on pace to be doing twice the business we were doing in less than 9 months after joining!

Our process has been streamlined, our turn times have been great and the help we have received has been 2nd to none! There are many companies out there that promise many things…..you all have delivered! We joined you all because of your core values. We flourished because you all take the time to teach branches how to run smoother, better and more profitable. Thank you again for all you and Hometown Lenders have done for us!!!!!”

Scott Moulton – Birmingham, Al

“I can’t tell you how refreshing it is to finally work for a branch company that follows through on all of the promises made during recruiting! This is especially true regarding growing our business – EVERY branch company says they will help with this. However, Hometown is the first that has given us the tools to get us to the next level. Although we don’t have the largest volume we still have the same resources available to us – we can request a rush to impress a client or call the president of the company up just to ask for advice. We truly feel like we’ve found our home at Hometown.

Jennifer Conley – Chillicothe, OH

“Whatever level you are currently at, HomeTown Lenders will boost you to new heights. I have been with HomeTown Lenders for several years & found these points to be a must to have, when growing my business. Most of all HomeTown has delivered the plan to success. HTL will personally strengthen your market share with their professional recruiters, in hiring top quality employees. HTL will strengthen your marketing game plan or craft a plan to your specific market, to get results and they back up what they say with uncompromising RESULTS! I have felt right at home with from day one with HomeTown Lenders!”

Dean Marshall – Knoxville, TN

Our Branches Say it Better Than We Ever Could!

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(TheNicheReport) — The Niche Report asks Eric Tishaw, the Chief Executive Officer of Hometown Lenders, what it takes to be successful and grow in a time when most are closing their doors.

First, tell us a little about Hometown Lenders.We started out over 12 years ago as just a small group of friends who wanted to originate loans together and have fun doing it. Over the years, our small company grew, mostly by referrals from our AE’s and other employees, and pretty soon we had branches all over our state with some really great people who are still here with us today. It didn’t take long before we grew to be the largest lender in our state and then to be one of the largest lenders in the South-East. As we grew, we invested in our company and in technology, and we also got very good at supporting all of our branches that were spread out all over the South. When we made the decision to become a retail branching operation, it was a logical growth progression as well as a natural extension of our abilities and expertise. We were able to scale our systems up to meet the requirements of operating a high number of retail branches in multiple states. During our growth, we never lost sight of the fact that we’ve always been a family-oriented business and that our people are what’s most important to us, and any of our partners will tell you that. We know what it’s like to have to generate business

by beating the streets for referrals and watching marketing costs like a hawk - we work very hard to provide the best platform possible for our people to be as successful as they want to be and we make them look like champions to their customers and referral partners. How has Hometown Lenders been able to thrive in a time when most of its competitors have closed up shop? Well, we started out with a unique philosophy that wasn’t popular or shared by anyone else in the

industry at the time….we were very selective about who we hired. For most companies, it was just a big volume grab, and they were hiring anyone who could bring them additional production. The problem turned out to be that a few bad apples spoiled their bunch, so in order to protect the company they had to overcompensate by implementing policies and restrictions which effectively put training

wheels on the good folks. Some major companies got shut down because of the poor quality of the loans being produced by some of the bad hires they made.

We took a different approach, and it paid off. I personally travelled to meet everyone we hired (or didn’t hire) in person to see if they were going to be a good fit with us, and to get a gut feeling regarding the quality of their loan production and personal character. Our position was that we would much rather have a branch doing less volume but one that fit well within our culture so that we didn’t lose sleep at night over their loans rather than to have big shops who might originate

Reprinted from The Niche Report magazine, August 2012 www.thenichereport.com

Questions and Answers with HomeTown!

Page 6: Hometown Lenders

questionable loans. The outcome for us was that we were able to grow at a consistent, measured pace with both big and small branches and achieve a level of success that was based on a solid foundation of top quality branches and producers. From there we were able to invest and support our branches and then let them do what they do best – close loans.

We’ve noticed your company is growing at a remarkable rate – what’s your secret to success? We strongly believe that it’s not enough to recruit good branches and then just hope they work out. We firmly believe that recruiting AND retaining is our top mission. This market is way too competitive to be good at recruiting only. If you don’t have a strong value proposition, your good people won’t stick around long, and your turnover costs will go through the roof. We are good at recruiting, but we genuinely enjoy developing and growing great branches. We developed this strategy years ago, and it has been very successful for our branches, so naturally we are very proud of that. We have been able to be a catalyst for some significant growth, and we have uncovered some amazing talent. We’ve seen some other companies trying to copy our approach recently, but we really enjoy the process and I think that is the real difference. We don’t do it because it sells well, we do it because we are good at it and we enjoy helping our branches grow. We’re helping them become champions, and they are helping grow their company to a whole new level. We have several different models for success in this industry, and we work with our branches to apply the one that makes the most sense for them. We have taken branches that were doing five loans per month and turned them into production powerhouses that close over 200 loans a month.

What’s your outlook on the industry? We are very optimistic about the future and the continued turnaround of our industry. We would love to see government regulators take a step back and let the free market pick the winners and the losers. We’ve seen a few signs that they may be easing up a bit, and we are particularly encouraged

by the recent barriers to entry that have been put into place, such as licensing regulations, compliance measures, and higher net worth requirements. Overall, we are very confident that the industry is heading in the right direction, and we feel that Hometown Lenders is well positioned to emerge as one of the industry’s new leaders in retail branching.

What else is HomeTown doing that other companies are not? Well, I don’t know that no one else is doing this, but one thing we feel very strongly about is our company-sponsored mission to help selected villages in Guatemala. Mission Firefly (www.missionfirefly.org) is a 501C that we created to fulfill what we believe is our greater calling in life. We enjoy giving back, and our people enjoy the opportunity to be a part of a great mission. Everyone in our company is welcome to go on trips with us, and it gives us a chance to break away from business now and then to focus on what’s really important in life. That’s probably not the answer you were looking for, but I think it ties in with what really sets us apart from our competitors - we believe that it’s our people that make us different. It sounds cheesy but its true – no other company has our people, and they are what makes Hometown Lenders great.

Eric Tishaw is the Chief Executive Officer of HomeTown Lenders. Recognized as a leader in the mortgage industry, Mr. Tishaw was recently included in National Mortgage Professionals “Top 40 under 40” list, and he was named

National Mortgage Professional of the Month. With over 12 successful years in the business, an MBA, and a lifetime of working in and around the mortgage business, Eric understands exactly what it takes to be successful in this industry. Eric Tishaw is committed to helping the Loan Originators and Mortgage Branch Managers at Hometown Lenders realize their fullest potential by utilizing and sharing the skills he has learned and the best practices he has observed throughout his career.

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How the On-Boarding Process works with HomeTown Lenders

1. Application 2. Branch Setup 3. Walk-Through 4. Submit Loans!

APPLICATIONThe first step is to apply for our program. You may either fill out the attached Branch Manager application and email it back to us OR you fill out the application online at www.hometownbranch.com - whichever you prefer.

Once we have received your completed application, we will perform a background and credit check and check your references. Once approved, we will send you the rest of the material to fill out to complete your employment and branch setup. (Initial approval generally takes 24-48 hours)

SETUP ITEMS Once your application is completely approved, you will be contacted by Chris Fiorello, our VP of Branch Operations, who will guide you through the rest of the process outlined below. Please plan to spend 20-30 minutes on the phone with Chris so that all items can be covered and all questions can be answered.

Branch Licensing - First, and most important, item of business. We have to get you legal. Accounting Setup - We’ll go over the paperwork that you will need to complete and who to submit it to.

Technology Access - And finally, we’ll get you setup to access all that HTL has to offer! Please note that Point and Credit access will revolve around your license approval. Everything else will be issued at this time.

YOU MAY START PUTTING LOANS IN RIGHT AWAY ONCE YOUR LICENSING IS COMPLETE!

On-Boarding Process

Call us today....so we can compare what you have now with what you could be getting with Hometown Lenders – (888) 606-8066 or email us at [email protected].

Page 8: Hometown Lenders

NMP MEDIA CORP.

1220 Wantagh Avenue • Wantagh, New York 11793-2202

516-409-5555 • Fax: 516-409-4600 • E-mail: [email protected]

NationalMortgageProfessional.com

Eric Tishaw, CEO of HomeTown Lenders isthe October 2013 National Mortgage Pro-fessional Magazine Mortgage Profession-

al of the Month. HomeTown Lenders is a37-branch retail lending organization based inHuntsville, Ala. HomeTown Lenders’ growth,innovative marketing and commitment to im-proving the conditions of the communities inwhich their employees live and work, as wellas the world at large, makes them worthy ofthis selection. I recently had the chance tospeak with Eric and uncover the passion be-hind the organization.

I understand that working in the mortgage in-dustry was your goal from your time in college.Tell me about that.They say that nobody intends to go into themortgage business. I’m actually the exceptionto that rule. I grew up around the mortgagebusiness, and was always really intrigued by it.I had some great friends growing up who werein the business. I was always really attracted toit. So my intention while in college was to gointo the mortgage business when I graduated.

What was so appealing about the industry?I think what appealed to me most is the constantchallenge—there is never a dull day in this busi-ness! But more importantly, we help people re-alize their dreams of owning a home. It’s a veryrewarding career.

How did you first get your start in the busi-ness?After college, I went to work as a loan originator.I really liked working with borrowers and edu-cating them so they could make a better in-formed decision. There is a lot of personalgratification in helping take their nervousnessout of the process. I soon made the move to be-come a branch manager. As a manager, I lovedhelping my employees mature and watchingthem sink the winning shot.

How did HomeTown Lenders come into being? When the market turned several years ago, ourcompany was forced to reinvent itself to survive. Atthat time, I began growing the company. We al-ready had branches and a branch support platformin place. Growing our branch network was a natu-ral extension of our abilities and expertise. Today,we have over 325 employees in branches fromFlorida to Colorado.

What is unique about your organization?What makes us unique is how we approach thebusiness, how we view it and our roles in helpingour partners grow. Our main philosophy revolvesaround three “R’s”: Recruit the best, Retain the bestand Remember who got us there.

With the first “R”, we are looking to Recruitthe best. We are always looking for top-tier cal-iber people with integrity. We are very selec-tive of who we hire. We don’t just hire anyonein order to get bigger.

The second “R” is Retention. We have astrong focus on retaining the best. A lot ofcompanies focus solely on recruiting, but weput a heavy focus on retention. We want toknow what the branches’ goals are and to helpthem get there and help support them as theygrow. We put a high priority on support, mak-ing sure when people call us that we answerthe phone. That is a big part of who we are.

Some companies make big promises, yetwe frequently hear people say, “They promised

Eric Tishaw, CEOHomeTown Lenders

BY DAV ID J . COSTER

NMP MORTGAGE PROFESSIONAL OF THE MONTH

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NMP MEDIA CORP.

1220 Wantagh Avenue • Wantagh, New York 11793-2202

516-409-5555 • Fax: 516-409-4600 • E-mail: [email protected]

NationalMortgageProfessional.com

me the moon, but after I started, I never heardfrom them.” HomeTown Lenders has dedicatedpersonnel and processes in place to help ourbranches and LOs meet their goals. We helpthem with marketing strategies, and we arepartnered up with some of the industries iconslike Frank and Brian from the National Real Es-tate Post, and Carl White and Scotty Hudspethfrom Mortgage Marketing Animals. We do thatin an effort to help our people realize their fullpotential and exceed their goals.

The third “R” is to always Remember why weare here … we are a Christian company, and we re-member that God is the reason for our success. Wehave been through some very difficult times thatunfortunately a lot of companies didn’t make itthrough. We give that credit to God.

This over-arching philosophy is the primary rea-son for our success.

You have also employed a unique advertisingcampaign that includes comic strips. What is be-hind that?It is definitely unique! Frequently, when talk-ing to branches, they would mention, “I wastalking to this company, and they promised methe moon. They said they would give me re-cruiting support and they would answer theirphone and give me all these things, but thenwhen I on board and it was, ‘How much areyou doing this month?’” I guess we heard it somuch that it became comical that other com-panies were just promising the moon but notdelivering. That’s really where the idea camefrom—just to make light of that fact.

As far as marketing is concerned, we justwanted a campaign that really stood out and wasdifferent. We are always getting feedback from peo-ple saying they love it. They appreciate that it’s dif-ferent, and they understand that we are differenttoo. We are maybe a little bit unconventional, butI think the comics are a good window into who weare. We like to have fun, but we are serious aboutbusiness.

You make a special effort to participate in char-itable work. Why is that?We exist for a greater purpose than just closingloans and making money. Our goal is to leave be-hind a legacy and to leave the world a better placethan we found it—to make real, positive, measur-able impacts on other people’s lives.

We created a company 501c3 organizationcalled Mission Firefly. It’s a mission organization toserve a village in Guatemala. We have built 13houses and seven clean water systems and have re-ally taken the Word to several places. We are start-ing to do that in other countries as well.

On a local level, there is a local home for boyswhere we sponsor events and support them withclothing, school supplies and tutoring. Most im-portantly, we spend time with them. That’s the key.Anybody can throw money at a problem, but it’sreally important for us to develop relationships andhelp these young kids grow into responsible adults.

Being in business, making money, closing loansand helping customers … that’s all great, but wedo it to allow us to serve a greater purpose. Wefirmly believe our role in leading or participatingin programs like this is critical and it falls in linewith our beliefs. Our message is quite simply toshow God’s love to others. The needs in the com-munities are amazing. It’s easy to sit back and saythat somebody else has that covered … they don’t.There are so many opportunities to be of service,we try to fill as many as we can.

What are your business goals?One of our primary goals right now is to continueour national expansion. We are actively enteringnew markets because we believe we have a greatmodel, and are simply expanding that to a widerarea. The next goal for us is to double our currentlevel of production.How would you describe the mortgage profes-sionals you are looking to add?We are looking for high quality, top tier talent. Weare looking for people that do clean, compliantbusiness. We have always viewed quality as better

than quantity, sometimes turning down the largevolume branches if we just don’t get a good feelingabout them. One of the things I still do today ismeet people in person before we hire them. I knowthat sounds crazy, but the reality is we want to knowwho we are working with. It needs to be a good fit.They are not just a number. The personal visitweighs very heavily in the branch approval process.

How would you make a pitch to a prospectivebranch manager?There are a bunch of companies out there, andeverybody offers the same basic platform. You doloans. You have products and programs and prices.It’s really all the same. What sets a great companyapart in my humble opinion is its people. How will-ing are they to help? Do they have a genuine desireto help? We have great people who understand thatour branches are our customers and do whatever ittakes to exceed expectations.

When prospects come through our office weoften hear, “Wow, these people are great. Everybodyis so great. They want to help.” That’s not by acci-dent. We have an experienced team that enjoyshelping. We have been together a long time. Every-body is on the same page about wanting to helpour partners and help them grow and make suretheir questions are answered. The greatest compli-ment we commonly hear is: “Man, this is night andday. My previous company wouldn’t even answerthe phone. They’re too busy.”

Our branches have a seat at the table. They havea voice. We regularly have events where we get to-gether and discuss what’s going on. They all havemy cell phone number. If they see something theydon’t like or they want to discuss an idea, the lineof communication is open. Some of our best ideascome from our branch managers. We want that tocontinue.

David J. Coster is senior editor of National Mort-gage Professional Magazine. He may be reachedby phone at (919) 559-2171 or [email protected].

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Mission Firefly exists to shine light into the darkness and to share the love of Christ with “the least of these”.

Our mission is to take the good news of Jesus Christ to the poor and needy of our world. Period.

As we prepare to follow God’s command to go into all the world and make disciples of all the nations, we focus on three things: spiritual discipleship, physical needs and economic stability.

Our steadfast goal is to mobilize and empower various groups of believers and local churches to do the same.

Our Philosophy:We will dream big, work tirelessly and persevere no matter what.

We build, organize, strategize, rejuvenate, transform, train, teach, lead, facilitate, serve, inspire and assist… We are partners, friends, mentors, leaders, teachers, servants and more.

Visit our website: www.missionfirefly.org

Our Strategy:We will accomplish our mission by creating solutions and duplicating our efforts in the local church... and then we will simply GO.

Mission Firefly seeks to help create sustainable solutions locally and around the world by focusing on five key areas of need: spiritual, physical, economic, health and education. We endeavor to duplicate these solutions by exposing other ministries and concerned individuals to the plight of those in spiritual and economic need.

Our goal is to help empower and enable local churches to develop long term relationships through short term mission trips and also give practical help to those who have little or no experience in missions.

Then, we will go.

Won’t you join us?

Page 11: Hometown Lenders

Application

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Welcome!Thank you for applying with HomeTown Lenders - the number one platform for the top-producing Branch Managers and Loan Originators!

Here at HomeTown Lenders, we strive to provide all of our employees with a productive, challenging, and compliant working environment that encourages individual accomplishment through continuous training and support. If selected to join our team, we will give you the tools and provide you with the support that you need to help you accomplish your goals.

Application ChecklistPlease complete this checklist to ensure the completeness of your application kit prior to submission for consideration.

Application Kit:• Employment Application• Background Check Form

Your submission must also include the following items:o Copy of your Drivers Licenseo Copy of your Social Security Cardo Copy of current commercial lease agreements (rent/equipment/etc) (branch managers only)o Current pay stub (loan officers and branch managers only)o Copy of your resumeo Copy of all state licenses held (loan officers and branch managers only)

Please send all items to:FAX - (256) 261-1984, orE-mail: [email protected]

“Home Town Lenders is an Equal Opportunity Employer”

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HomeTown Lenders, LLCEmployment Application

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BACKGROUND CHECK AUTHORIZATION AND RELEASE

A background check is required for each new prospective Employee:

1. In connection with my application for employment, I understand that a consumer report or an investigative consumer report may be requested that will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment. I understand that as directed by my company policy and consistent with the job described, you may be requesting information from public and private sources about my workers compensation injuries and claims, driving record, court record, education, references and credit. Also, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

2. Medical and workers compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a consumer-reporting agency. If so, I will be notified and given the name and address of the agency or the source, which provided the information.

3. I acknowledge that a fax or photocopy shall be as valid as the original.

4. I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or Insurance Company be contacted by HOMETOWN LENDERS LLC or its agent, to furnish the information described herein. The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes. I hereby release the employer and agents and all persons, agencies, and entities providing information on reports about me from any and all liability arising out of the requests for release of any of the above mentioned information or reports.

_________________________________________________________Print (Last, First, Middle)

_________________________________________________________Print Prior Name(s) (Last, First, Middle)

__________________________________________________________________________________

__________________________________________________________________________________Street Address/City/State/Zip

Date of Birth _____________________ Social Security Number: ____________________________________

The following states require sex and race to obtain information: AL, FL, GASex: o Male o Female Race: o Asian o Black o Hispanic o White o Other

Drivers License Number ______________________________

State Issuing License __________ Name as it appears on license ________________________________

Signature ______________________________ Date __________________

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CHAMBLEE POLICE DEPARTMENTCRIMINAL HISTORY CONSENT FORM

I hereby authorize ______________________________________________________________to receive any Georgia criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia.

_____________________________________________________________________________Full Name (print)

_____________________________________________________________________________Address

_____ _____ __________________ _________________________Sex Race Date of Birth Social Security Number

___________________________________________________Signature

__________________Date

Special employment provisions (check if applicable):

o Employment with mentally disabled (Purpose code ‘M’)o Employment with elder care (Purpose code ‘N’)o Employment with children (Purpose code ‘W’)

One of the following must be checked:

o This authorization is valid for 90/180/_____ (circle one) days from date of signature.

o I, _______________________________________________ give consent to the above named to perform periodic criminal history background checks for the duration of my employment with this company.

CH CLERK:__________________________________________ DATE: ______________