Authorization for Release of Consumer Information

AUTHORIZATION FOR RELEASE OF CONSUMER INFORMATION

(EMPLOYMENT PURPOSE)

TO BE COMPLETED BY APPLICANT/EMPLOYEE

(PLEASE PRINT LEGIBLY OR TYPE)

NAME ______

Last Name First Name Middle Initial

DATE OF BIRTH: _____/____/_____ SOCIAL SECURITY #: ______

Month Day Year

DRIVER’S LICENSE #: ______STATE: ______

***Please note that if you are applying for a position with Home Health, Housekeeping, Maintenance, Courier, Transmed, Physical Therapy or any other department which may require you to operate a vehicle on company time you must have a valid driver’s license and no history of any major traffic violations (DUI, wreckless driving, multiple speeding tickets, etc…). We will be conducting a driver’s license check in addition to the other required checks. If you are applying for one of those positions please answer the following…

____ I have a valid license with no major violations in my background

____ I do not meet the requirements at this time

ADDRESS: ______

Street Address

______

City State Zip Code

APPLICANT/EMPLOYEE SIGNATURE: ______

Applicant Information

Without reservation, I authorize this employer or any party or agency contacted by this employer to procure my consumer report and/or to obtain or furnish information concerning my credit, criminal, motor vehicle, employment or other history. I understand that inquiries may be made to various federal and state agencies, employers, references, acquaintances and others seeking information as to my personal characteristics, credit worthiness, employment status, general reputation, and mode of living. I authorize this employer to order pre-employment background checks as well as annual and/or random background checks in accordance with company policies throughout the term of employment should I be hired.

Under provisions of the Fair Credit Reporting Act, certain information when used for employment purposes is considered to be a consumer report. This information includes, but is not limited to, public record information (criminal history, civil litigation, etc.), driving records, consumer credit history, education records, and employment records. If an adverse employment decision is made due, in whole or in part, to information received as a result of these inquiries, I understand that I have the right to obtain a copy of the criminal records report from the health care employer, to challenge the accuracy of the report, and to request a waiver in accordance with my rights under the Fair Credit Reporting Act.

Print Full Name: ______

Social Security Number: ______*Date of Birth: ______

Signature: ______

*This information is requested by VERIFY solely for purposes of insuring accurate retrieval of records.

TO BE COMPLETED BY EMPLOYER (PLEASE PRINT LEGIBLY OR TYPE)

Company/Organization: ______Sparta Community Hospital______

Mailing Address: ______P.O. Box 297; Sparta, IL 62286______

Contact Person: ______Darla Shawgo______

Telephone #: (618) 443-1406 FAX#: (618) 443-1349

Form # 335 07/11/11