EDUCATION HISTORY

FORMER EMPLOYERS (LIST BELOW LAST FOUR EMPLOYERS, STARTING WITH LAST ONE FIRST)

EMPLOYER 4

FORMER EMPLOYERS (LIST BELOW LAST FOUR EMPLOYERS, STARTING WITH LAST ONE FIRST)

EMPLOYER 3

EMPLOYER 2

EMPLOYER 2

REFERENCES

LIST NAMES BELOW OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR

REFERENCE 1

REFERENCE 2

REFERENCE 3

REFERENCE 4

AUTHORIZATION PLEASE READ BEFORE SIGNING

I certify that all answers and statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing which, if disclosed, might affect this application unfavorably. I understand that any falsification, misrepresentation or material omission of information submitted on this application will constitute grounds for denial or immediate dismissal employment.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. 

I also understand that employment is based on the ability to pass a pre-employment drug screening and that failure of drug screening may cause action of dismissal

I understand OTHER pre-employment eligibility guidelines may have to be accomplished as well.

Signature _______________________

ALLGRACE HEALTHCARE SOLUTIONS

BACKGROUND CHECK AUTHORIZATION FORM

Information is used solely for ensuring completion of a criminal record check; many jurisdictions use name and date of birth as the two primary identifiers of an individual’s record. The age discrimination employment act of 1967 prohibits employers from discriminating on the basis of age, with respect to individuals who are 40 years of age and older.

PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING THIS AUTHORIZATION FORM

I understand that as part of you procedure for processing my application, an investigation report about my background may be made which may include information obtained through personal interviews, regarding my character, general reputation, personal characteristics or mode of living. I have the right to make a written request, within a reasonable period of time, for complete disclosure of additional information concerning the nature and scope of the investigation. I authorize investigation of all statements contained in this authorization form. All representations by me in this data sheet are to the best of my knowledge and belief true and correct, and I have not knowingly omitted any related information of an adverse nature. Inaccurate information may make me ineligible for employment. I also understand that having a criminal conviction is not an automatic bar for employment. In the absence of a written contract of employment, employment with the agency is employment at the will of each party. The employment relationship may be terminated at any time at the discretion of the employee or agency

Signature _______________________

Agency Signature _______________________