Pre-Hire Caregiver Application - Background Release

  • In connection with my application for employment, including contract for service, with Alarys Home Health (“the Company”), I understand that investigative inquiries may be obtained on myself by a consumer reporting agency, and that any such report will be used solely for employment-related purposes. I understand that the nature and scope of this investigation will include a number of sources including, but not limited to, consumer credit, criminal convictions, motor vehicle, and other reports. These reports will include information as to my character, general reputation, personal characteristics, mode of living, and work habits. Information relating to my performance and experience, along with reasons for termination of past employment from previous employers, may also be obtained. Further, I understand that you will be requesting information from various Federal, State, County and other agencies that maintain records concerning my past activities relating to my driving, credit, criminal, civil, education, and other experiences.

    I understand that if the Company hires me, it may request a consumer report or an investigative consumer report about me for employment-related purposes during the course of my employment. The scope of this investigation will be the same as the scope of a pre-employment investigation, and that the nature of such an investigation will be my continuing suitability for employment, or whether I possess the minimum qualifications necessary for promotion or transfer to another position. I understand that my consent will apply throughout my employment, unless I revoke or cancel my consent by sending a signed letter or statement to the Company at any time, stating that I revoke my consent and no longer allow the Company to obtain consumer or investigative consumer reports about me. I understand that I am being given a copy of the “Summary of Your Rights Under the Fair Credit Reporting Act” prepa red pursuant to 15 U.S.C. Section 1681-1681u.

    This Disclosure and Consent form, in original, faxed, photocopied or electronic form, will be valid for any reports that may be requested by the Company. I authorize without reservation any party or agency contacted by this employer to furnish the abovementioned information. I hereby consent to your obtaining the above information from USAintel (and/or any of their licensed agents). I understand to aid in the proper identification of my file or records the following personal identifiers, as well as other information, as necessary

  • Please list current and previous address(es) if current is less than 1 year.