PRE-EMPLOYMENT BACKGROUND CHECK AUTHORIZATION

PRE-EMPLOYMENT BACKGROUND CHECK AUTHORIZATION
I understand that as part of the employment process, Edwards Direct Home Care Agency need to complete a background check on me regarding:
1. Criminal record
2. Motor Vehicle Records
3. Sex and Violent Offenders Record.
4. Personal/Professional Reference Verification
5. Employment Verification
6. Medical Suitability
7. Education Verification
8. License Verification Drugs/Alcohol
Please Check All to Acknowledge:
Name*

First NameLast Name
Former Names Used

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number*
Telephone No.*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
First NameLast Name
List any other cities, states, and dates of residency during last 10 years
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date

MonthDayYear
Date
Name*

First NameLast Name
Signature*

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