Liberty County Hospital & Nursing Home Inc.

 

I (print name) ______________________________ hereby authorize Liberty County Hospital and Nursing Home, Inc. (herein known as “Company”) and TRAK – 1 (herein known as “Service Provider”) to request and receive any and all background information about or concerning me, including but not limited to my Criminal History, Credit History including a consumer report under the Fair Credit Reporting Act, 15 U.S.C. 1681,et seq. (the “Act”), Driving Record, Employment History, Military Background, Civil Listings, Educational Background, Professional License from any Individual, Corporation, Partnership, Law Enforcement Agency, Institution, School, Organization, Credit Bureau, State Boards, Licensing Agency, and other entities including my Present and Past Employers.

I further release and discharge Liberty County Hospital and Nursing Home and it’s “Service Provider” (Trak-1) and all of their Subsidiaries, Affiliates, Officers, Employees, Contract Personnel, or Associates, from any and all claims and liability arising out of any request(s) for, or receipt of, information or records pursuant to this authorization, procurement of an investigative consumer report and understand that it may contain information about my character, general reputation, personal characteristics, and mode of living, whichever are applicable. 

I understand that I have the right to make written request within a reasonable period of time to the “Service Provider” (Trak-1) for additional information concerning the nature and scope of investigation.  I acknowledge that I have voluntarily provided the above information for employment purposes, and I have carefully read and I understand this authorization.

Are you applying for employment in California, Georgia, Minnesota or Oklahoma?

(Circle One) Yes or No

If so, do you want a copy of any Consumer Report prepared concerning you?

(Circle One) Yes or No

I understand that California law requires Company to give me a copy of any report requested within seven (7) days of the date the information was obtained and that failure to do so will expose Company to liability.

 

Signed: ____________________________       Date: ___________________________

Name (print): _______________________        Previous (former) Names____________

Social Security #: ____________________        Date of Birth: _____________________

Drivers License #: ____________________       State Issued: ______________________