Post Hire Packet

**Please have these files handy for uploads:
- License, Passport, or Social Security Card
- Education Degree
- Resume
Applicant Name*

First NameLast Name
Social Security #*
Gender

MaleFemalePrefer not to say
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
NPI (If Applicable)
In case of an emergency, please notify:
Name*

First NameLast Name
Cell Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email
example@example.com
I, blanks, confirm that I am in good health, free of communicable disease and am fit to provide therapeutic and or educational services to clients
Allergies
Signature*

Clear
Date*

MonthDayYear
Date
Reference Form

** Applicant Completes this section
Date*

MonthDayYear
Date
Reference 1
Supervisors Name*

First NameLast Name
Company Name*
Title
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Positions Held
Dates of Employment
From*

MonthDayYear
Date
To*

MonthDayYear
Date
Reference 2
Supervisors Name*

First NameLast Name
Company Name*
Title
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Positions Held
Dates of Employment
From*

MonthDayYear
Date
To*

MonthDayYear
Date
I HEARBY RELEASE FROM ALL LIABILITY THE COMPANY OR PERSON COMPLETING THIS FORM AND AUTHORIZE THEM TO RELEASE ALL INFORMATION REGARDING MY EMPLOYMENT WITH THEM
Applicant Full Name*

First NameLast Name
Applicant Signature*

Clear

Background Check Authorization
I instruct and authorize Path 2 Potential to obtain a consumer report(s) (or background check report(s)) on me, including any investigative consumer reports and any consumer credit reports.* I also agree that a copy of this form is valid like the signed original.

The consumer reporting agency (CRA) ADP Screening and Selection Services, Inc. (ADP SASS) will conduct the background check and prepare the background check report for the Company. ADP SASS is located at 301 Remington Street, Fort Collins, CO, 80524, and can be reached by phone at 800-367-5933, or at www.adpselect.com.

I understand that, as allowed by applicable law, the Company may rely on this authorization to order additional background check reports, including investigative consumer reports and any consumer credit reports* (1) during my employment or time as a volunteer or independent contractor, as applicable, and (2) from any CRA other than ADP SASS without asking me for my authorization again. I understand the Company may order background check report(s) under my legal name and any other names I may have used.

I also instruct and authorize the following persons, agencies, and entities to disclose to ADP SASS and its agents all information about or concerning me, as allowed by law, including but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. As allowed by law, such disclosures may contain the following information pertaining to me: credit history*; public records; a Social Security number verification; driving records; military service; credentials/certifications; worker's compensation injuries; and verification of prior employment and education

*I understand that I am instructing and authorizing the Company to obtain a consumer credit report only to the extent permitted by law. If I reside or anticipate being employed in New York City, I understand that I am not being asked to authorize a consumer credit report by signing this document.

By signing below, I understand that I am agreeing to the terms contained in this document.
If you live or work for the Company in California, Minnesota, or Oklahoma

Check this box if you would like a free copy of your background check report
Please print your full legal name
Name*

First NameMiddle NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

Background Check Information
The information requested below is collected solely for the purpose of aiding the Consumer Reporting Agency (CRA) in completing a background check on you.
Name*

First NameMiddle NameLast NameSuffix
Email*
example@example.com
Date of Birth

MonthDayYear
Date
Social Security #*
Drivers License Number
State issuing License
Enter nickname(s) used
Enter any other names used if applicable
Name

First NameMiddle NameLast Name
Name

First NameMiddle NameLast Name
Name

First NameMiddle NameLast Name
Address within the past 7 years
Current

Present Street Address

Present Street Address Line 2

Present CityPresent State / Province

Present Postal / Zip Code
Prior

Prior Street Address

Prior Street Address Line 2

Prior CityPrior State / Province

Prior Postal / Zip Code
From

MonthDayYear
Date
To

MonthDayYear
Date
Choose 2 forms of Identification*

Driver's LicenseSocial Security CardPassport
Driver's License Identification*

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Social Security Card Identification*

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Passport Identification*

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Education Degree Verification (Diploma or Transcript)*

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Updated Resume *

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Photo (neck up) for ID badge

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Child Abuse / Mandated Reporter Training Certificate

Cancelof
If you need to take a training, you can do so here: https://ocfs.ny.gov/main/cps/Mandated_Reporter_Training.asp
Other Documents

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Should be Empty:

In case of an emergency, please notify:

Reference Form

Reference 1

Reference 2

Background Check Authorization

Background Check Information

Enter any other names used if applicable