Western Express Lending

(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

Education, Training and Experience

School

High School

College/University

Vocational/ Business

EMPLOYMENT HISTORY/CERTIFICATION

Answer the following questions if you are applying for a LICENSED OR CERTIFIED position:

Employment History

List below all present and past employment starting with your most recent employer (last five years is sufficient). Account for all periods of unemployment. You must complete this section even if attaching a resume.

MILITARY HISTORY - REFERENCES

References

List below three persons not related to you who have knowledge of your work performance within the last three years.

Employment Process Items

Please Read Carefully, Initial Each Paragraph and Sign Below

AUTHORIZATION FOR BACKGROUND CHECKS

I instruct and authorize Western Express Lending (the “Company”) to obtain a consumer report(s) (or background check
report(s)) on me, including any investigative consumer reports and any consumer credit reports.* I also agree that a copy of this form is valid like the signed original.

The consumer reporting agency (CRA) ADP Screening and Selection Services, Inc. (ADP SASS) will conduct the background

check and prepare the background check report for the Company. ADP SASS is located at 301 Remington Street, Fort Collins, CO, 80524,

and can be reached by phone at 800-367-5933, or at www.adpselect.com.

I understand that, as allowed by applicable law, the Company may rely on this authorization to order additional background

check reports, including investigative consumer reports and any consumer credit reports* (1) during my employment or time as a volunteer or independent contractor, as applicable, and (2) from any CRA other than ADP SASS without asking me for my authorization again. I understand the Company may order background check report(s) under my legal name and any other names I may have used.

I also instruct and authorize the following persons, agencies, and entities to disclose to ADP SASS and its agents all information about or concerning me, as allowed by law, including but not limited to: my past or present employers; learning institutions,
including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me.

As allowed by law, such disclosures may contain the following information pertaining to me: credit history*; public records; a Social Security number verification; driving records; military service; credentials/certifications; worker’s compensation injuries; and verification of prior employment and education.

BACKGROUND CHECK INFORMATION

The information requested below is collected solely for the purpose of aiding the Consumer Reporting Agency (CRA) in completing a background check on you.

Enter Any Other Names Used (including maiden names):

Addresses Within The Past Seven Years (use a separate sheet as needed)