I have carefully read and understand this Employment Background Disclosure and Authorization Form. I understand that if Galaxy Home Care hires me, my consent will apply to all required reports and Galaxy Home Care may obtain reports throughout my employment. I also understand that information contained in my job application or otherwise disclosed by me before or during my employment, if any, may be used for the purpose of obtaining the required information. The types of information that may be obtained include, but are not limited to: social security number verification; criminal records checks; public court records checks; driving records checks; educational records checks; employment verifications; personal and professional references checks; licensing and certification records checks; drug testing results; etc. The information contained in the reports will be obtained from private and public record sources including, as appropriate, personal interviews with sources, such as neighbors, friends, and associates. By my signature below, I authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, record/data repositories, courts (federal, state, and local), motor vehicle records agencies, my past or present employers, and other individuals and sources to furnish any and all information on me that is requested by Galaxy Home Care. By my signature below, I certify the information I provided on my employment application, and/or resume, and this form to be true and correct. I also agree that falsified information or significant omissions may disqualify me and may be considered sufficient justification for dismissal if discovered at a later date. I agree that this Disclosure and Authorization Form in original, faxed, photocopied, or electronic form (including electronically signed) will be valid for any reports that may be requested by or on behalf of Galaxy Home Care Agency.