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OFFICE OF THE CLARK COUNTY CLERK SHIRLEY B. PARRAGUIRRE

RELEASE AND AUTHORIZATION FOR BACKGROUND INVESTIGATION

In connection with my application for Authorization to Solemnize Marriages in the State of Nevada pursuant to NRS 122.064, subsection 3 (c), I hereby authorize Shirley B. Parraguirre, Clark County Clerk, and Screening One, Inc. to perform a background screening check (including future screenings for retention, if applicable, and unless revoked by Applicant in writing). I understand and agree to the following: 1. A background check is not only for the benefit of the Clark County Clerk as a sound business practice, but also for the benefit of the public. It is no reflection on an applicant. The report consists of information deemed to have a bearing on the decision to grant authorization to solemnize marriages in the State of Nevada, and may include information from public and private sources and public records. The scope of the report may include information concerning civil and criminal court records, identity, past addresses and social security number and is conducted in accordance with applicable federal and state laws. 2. All reports are confidential, and provided to the Clark County Clerk for decisions concerning authorization to solemnize marriages only. 3. I may review or obtain a copy of my report as provided by law. Screening One may be contacted by writing to: Screening One, Inc., 2233 W. 190th Street, Torrance, CA 90504. 4. I authorize and release people, companies, municipal, county, state and federal agencies and courts to provide all information that is requested to the Clark County Clerk or Screening One. 5. I further release all of the above, including the Clark County Clerk and Screening One, to the full extent permitted by law, from any liability or claims arising from retrieving and reporting information concerning me. 6. I agree that a copy or fax of this document shall be as valid as the original.

I, _________________________________________________________________ ,
(Print name legibly)

hereby consent and authorize the Clark County Clerk and/or Screening One, Inc., on the Clark County Clerk's behalf, to prepare each report as defined above to assist in making decisions relating to granting authorization to solemnize marriages in the State of Nevada, before such decision to grant authorization or anytime after such authorization.

Signature _____________________________________

Date ___________________