Authorization for Background Screening

This form authorizes AccuGen Diagnostics LLC to verify your identity and complete a background screening required for the services you are requesting. Your information is kept confidential and used solely for verification and compliance purposes.

Purpose of Background Check

AccuGen Diagnostics LLC may conduct a background check for the purpose of verifying identity and completing required screening related to services requested by the client or referring organization.

This background check may include verification of:

• Identity information

• Address history

• Criminal records (if applicable)

• Other publicly available records relevant to identity verification

Disclosure

DISCLOSURE AND AUTHORIZATION FOR BACKGROUND INVESTIGATION

AccuGen Diagnostics LLC (“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” as defined by the Fair Credit

Reporting Act (FCRA).

These reports may include information about your character, general reputation, personal

characteristics, and/or mode of living. The types of information that may be obtained

include, but are not limited to:

- Social Security number verification

- Criminal history records (county, state, federal, national databases)

- Sex offender registry searches

- Employment history and verification

- Education verification

- Professional license verification

- Motor vehicle records (driving history)

- Credit history (where permitted by law)

- Drug testing results (if applicable)

- Other background checks as permitted by law and relevant to your role

Investigative consumer reports may involve personal interviews with sources such as your

neighbors, friends, or associates.

You have the right, upon written request made within a reasonable time after receipt of this

notice, to request:

1. Whether an investigative consumer report has been obtained; and

2. A description of the nature and scope of the investigation.

AUTHORIZATION

I, the undersigned applicant/consumer, hereby authorize AccuGen Diagnostics LLC and its

designated agents and representatives to obtain consumer reports and/or investigative

consumer reports about me for employment purposes.

I understand that this authorization applies to initial background screening and, if

applicable, ongoing monitoring or subsequent reports during my employment or contract

period.

I authorize all individuals, organizations, and entities (including but not limited to

employers, educational institutions, law enforcement agencies, courts, and licensing

authorities) to release information about me to AccuGen Diagnostics LLC.

I release AccuGen Diagnostics and all providers of information from any liability arising from

the furnishing or use of such information.

ADDITIONAL STATE LAW NOTICES (IF APPLICABLE)

Certain states provide additional rights. If you are a resident of California, New York,

Minnesota, Oklahoma, or other applicable states:

- You may have the right to request a copy of your consumer report.

- You may request additional disclosures regarding the nature and scope of the

investigation.

Authorization & Consent

By completing this form, I acknowledge that I have received and reviewed the required disclosures regarding the background check process. I understand that AccuGen Diagnostics LLC may obtain a background report for identity verification, compliance, and service‑related screening purposes.

I authorize AccuGen Diagnostics LLC and its designated background screening provider to obtain information from law enforcement agencies, government agencies, educational institutions, previous employers, and other authorized data sources as permitted by law. This authorization applies to the initial screening and, if applicable, any future screenings required for continued services or compliance.

By selecting “I AGREE,” typing my full name, and providing the last four digits of my Social Security Number or User ID, I am providing my electronic signature and giving permission for AccuGen Diagnostics LLC to proceed with the background check. I understand that this authorization is voluntary but required to complete my service request

Client Signature

AccuGen Diagnostics

AccuGen acknowledges receipt of this authorization and agrees to use the information solely for the stated purpose.

Authorized Representative: Aliya Simpson CPT