After carefully reading this Background Check Disclosure and Authorization form attached summary of rights under the Fair Credit Reporting Act. By my signature below, I consent to preparation of background reports by a consumer reporting agency such as HireRight,lnc ("HireRight") and to the release of such background report, including investigative consumer reports to the Home Care RN Inc and its designated representatives and agents for the purpose of assisting the Home Care RN Inc in making a determination as to my eligibility for employment(including independent contractor assignments, as applicable),promotion, retention or for other lawful employment purposes. I understand that if the Home Care RN Inc hires me or contracts for my services, my consent will apply, and Home Cere RN Inc may rely on this authorization to order additional background reports, including investigative consumer reports, during my employment without asking me for my authorization again as allowed by law.
I understand that information contained in my employment or contractor application, or otherwise disclosure by me before or during my employment or contract assignment, if any, may be used for the purpose of obtaining and evaluating background reports on me. I also understand that noting herein shall be construed as an offer of employment or contract for services.
I hereby authorize all of the following, without limitation, to disclose information about me to the consumer reporting agency and its agents: law enforcement and all other federal , state and local agencies, learning institutions (including public and private schools, colleges and universities), testing agencies, information service bureaus, credit bureaus, record/date depositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and all other individuals and sources with any information about or concerning me. The information that can be disclosed to the consumer reporting agency and its agents includes, but is not limited to, information concerning my employment and earnings history , education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses.
By my signature below, I also certify that all of the personal information I provided is true and correct.
I agree that this form in original, faxed, photocopied or electronic (including electronically signed) form, will be valid for any background reports that may be requested by or on behalf of the Home Care RN, Inc.