Disclosure Regarding Background Investigation & Authorization
DISCLOSURE AND ACKNOWLEDGEMENT (IMPORTANT — PLEASE READ CAREFULLY BEFORE SIGNING ACKNOWLEDGEMENT)
HH Health System -Jackson, LLC may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, criminal and civil litigation history information, motor vehicle records (“driving records”), sex offender status, education verification, professional license, drug testing, Social Security Verification, employment history, and personal history (only once a conditional offer of employment has been made). You have the right, upon written request made within a reasonable time after receipt of this notice, to request whether a consumer report has been run about you, and the nature and scope of any investigative consumer report, and request a copy of your report.
ACKNOWLEDGEMENT AND AUTHORIZATION
I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. In consideration of my application, I authorize Highlands Medical Center by and through to verify all data given by me on my application, related papers or oral interviews. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any employers, agencies, personal references, law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau or insurance company and other persons with whom I am acquainted to answer all questions and release all information including but not limited to my employment record, character, reputation, ability, education, military service, credit history and other applicable reports and/or furnish any and all background information requested by ESS, or another outside organization acting on behalf of HH Health System - Jackson, LLC. Furthermore, I release all agencies, bureaus, employers, information service organizations and individuals or companies named above from all liabilities or damages that might result from information provided in good faith. I state that the information provided by me on my application is accurate and I agree that if any information is found to be false at any time, my application may be discarded or my employment terminated. I understand that the information requested below regarding sex and date-of-birth are for the sole purpose of gathering the above information accurately and will not be used to discriminate against me in violation of the law. I agree that a facsimile (“fax”), electronic or photographic copy of the Authorization shall be as valid as the original.
Highlands Medical Center Human Resources Department
The following information is required to assist HH Health System -Jackson, LLC in complying with Federal / State equal employment opportunity reporting and other legal requirements. Please answer all questions below.
Note: This invitation to identify yourself as a member of a protected group is subject to the following:
· This information is voluntarily provided;
· This information will be kept in a confidential file separated from employment applications or personnel files;
· Refusal to provide the requested information will not subject the employee applicant or applicant to any adverse treatment.