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Authorization for Background Investigation

To Whom It May Concern:

I, , hereby authorize Maxum Petroleum and/or its agents to make an independent investigation of my background, which may include my character, general reputation, personal characteristics, and mode of living in connection with an application of employment with Maxum Petroleum, Inc.

The scope of the report may include information concerning my driving record, civil and criminal court records, credit, worker’s compensation record, education, credentials, identity, past addresses, social security number, previous employment and personal references.

I authorize and request any present or former employer, state/federal government office, state department of motor vehicles, credit bureaus, school, police department, court records, including those maintained by both public and private organizations, financial institution or other persons having personal knowledge about me to furnish Maxum Petroleum, Inc. with any and all information in their possession regarding me for the purpose of confirming the information contained on my Application and/or obtaining other information which may be material to my qualifications for employment. I am willing that a photocopy of this authorization be accepted with the same authority as the original, and I specifically waive any written notice from any present or former employer who may provide information based upon this authorization request.

The following is my true and complete legal name and all information is true and correct to the best of my knowledge:

Please provide a telephone/cell number where we may contact you.

Phone:

Signature:

Date:

2011 Maxum Petroleum, Inc.

500 River East Drive | Belle, WV 25015 | (304) 926-3002 | www.maxumpetroleum.com

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