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This Agreement entered into on ______________________, 20__ between Laborchex, Inc., hereinafter referred to as ("Laborchex"), a Mississippi Corporation, and _____________________________.

WHEREAS, Section 1 of Act 465 of the 1977 Acts of Arkansas provides that the Office of Driver Services, Revenue Division, Department of Finance and Administration, State of Arkansas, may furnish an abstract of a driver’s record as maintained by said office, only to a person who has been authorized in writing by such driver to obtain the driver’s record; and

NOW, THEREFORE, IN CONSIDERATION OF THE FOREGOING, THE UNDERSIGNED DOES HEREBY ACKNOWLEDGE AND CERTIFY AS FOLLOWS:

1. That the undersigned represents and warrants to Laborchex, Inc., that every person on whom a request for an abstract is made by the undersigned, shall have first given his or her consent to the release of such abstract.

2. That the original written authorization signed by the driver on whom an abstract is requested, or copy thereof, shall be furnished by the undersigned to Laborchex.

3. The undersigned further agrees to indemnify and hold harmless Laborchex, for any liabilities and / or damages caused by virtue of the undersigned’s breach of this agreement of the provision of Act 456 of the 1977 Acts of Arkansas.