BACKGROUND REPORT RELEASE FORM

BY FILLING OUT THE INFORMATION BELOW AND CLICKING ‘SUBMIT’, I AUTHORIZE International Assisted Reproduction Center to obtain a Consumer Report and/or Background Report on me. This authorization is valid for purposes of verifying information given pursuant to employment, leasing, rental, business negotiations, or any other lawful purpose covered under the Fair Credit Reporting Act (FCRA). The Background Check may contain information available in the Public Domain but may not include interviews with persons other than previous employers or their agents. By filling out the information below and clicking ‘SUBMIT’, I hereby authorize all corporations, former employers, credit agencies, educational institutions, law enforcement agencies, city, state, county and federal courts and agencies, military services and persons to release all information they may have about me including criminal and driving history. This authorization shall be valid in original or copy form from date of execution and continuing for as long as I remain in IARC’s program.

First Name* *

Last Name* *

If you are the spouse or significant other of a potential surrogate, what is her name?

Social Security Number* *

Date of Birth* *

Address *

Address

City

State/Province

Zip/Postal

Driver's License #* *

Driver's License State* *

Signature* *

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