• PRE-EMPLOYMENT BACKGROUND CHECK AUTHORIZATION

    PRE-EMPLOYMENT BACKGROUND CHECK AUTHORIZATION

  • PRE-EMPLOYMENT BACKGROUND CHECK AUTHORIZATION

    I understand that as part of the employment process, Divine Purpose Care Residential Services needs to complete a background check on me regarding:

  • 1.Criminal record 2. Sex and Violent Offenders Record 3. Employment Verification 4. Education Verification 5. License Verification (if indicated) 6. Motor Vehicle Records (if indicated) 7. Personal/Professional Reference Verification 8. Medical Suitability 9. Drugs/Alcohol 10. Child Abuse Clearance (if indicated)

  • I authorize all federal and state agencies, persons and organizations that may have information relevant to this research to disclose such information to Divine Purpose Care Residential Services or its authorized agent(s).

  • I understand that this authorization is to be part of the written and signed employment application.

  • I also understand that I do not have to give authorization for a background check but if I don’t give permission, my employment application will not be processed further.

  • I understand that I have specific rights under the federal Fair Credit Reporting Act (FCRA) and may have additional rights under relevant State law.

  • I further authorize that a photocopy of this authorization may be considered as valid as the original.

  • I hereby certify that all statements on this form are true and correct to the best of my knowledge and belief. I understand that employment with Divine Purpose Care Residential Services is contingent upon successful completion of a background check.
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  • Application for Employment

  • EDUCATIONAL BACKGROUND

  • SCHOOL:      
    CITY, STATE/PROVINCE:            
    GRADUATED?:   Yes   No 
    DEGREE(s)/DIPLOMA(s) EARNED:      

    SCHOOL:      
    CITY, STATE/PROVINCE:            
    GRADUATED?:   Yes   No 
    DEGREE(s)/DIPLOMA(s) EARNED:      

    SCHOOL:      
    CITY, STATE/PROVINCE:            
    GRADUATED?:   Yes   No 
    DEGREE(s)/DIPLOMA(s) EARNED:      

  • What Nursing or relevant designations, licenses or registrations if any, do you possess?
    Type:   
    Date of Most Recent Registration:   Pick a Date   
    Valid in State/Province ?:      

    Type:   
    Date of Most Recent Registration:   Pick a Date   
    Valid in State/Province ?:      

    Type:   
    Date of Most Recent Registration:   Pick a Date   
    Valid in State/Province ?:      

    Do you have the following:
    CPR:         Last Certified:   Pick a Date   
    First Aid:        Last Certified:      
    WHMIS:        Last Certified:   Pick a Date   

  • PLEASE ANSWER THE FOLLOWING QUESTIONS

  • EMPLOYMENT BACKGROUND

    Provide the following information beginning with the most recent employer.

  • EMPLOYER:      TELEPHONE:      DATES EMPLOYED: FROM:      TO:      
    HOURLY RATE/SALARY:      JOB TITLE:    
    IMMEDIATE SUPERVISOR NAME:         
    REASON FOR LEAVING:    
    MAY WE CONTACT FOR REFERENCE?:                

    EMPLOYER:      TELEPHONE:      DATES EMPLOYED: FROM:      TO:      
    HOURLY RATE/SALARY:      JOB TITLE:    
    IMMEDIATE SUPERVISOR NAME:         
    REASON FOR LEAVING:    
    MAY WE CONTACT FOR REFERENCE?:              

    EMPLOYER:      TELEPHONE:      DATES EMPLOYED: FROM:      TO:      
    HOURLY RATE/SALARY:      JOB TITLE:    
    IMMEDIATE SUPERVISOR NAME:         
    REASON FOR LEAVING:    
    MAY WE CONTACT FOR REFERENCE?:              

  • REFERENCES

    List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please).

  • NAME:         
    RELATIONSHIP:      
    YEARS ACQUAINTED:      
    PHONE NUMBER:         

    NAME:         
    RELATIONSHIP:      
    YEARS ACQUAINTED:      
    PHONE NUMBER:         

    NAME:         
    RELATIONSHIP:      
    YEARS ACQUAINTED:      
    PHONE NUMBER:         

  • Heading

    I certify that all the information I have provided is true, complete and correct.The information contained within this application, or any cover letter or resume attached is not shared with any third parties. The information is used by the employer only as an aid in the hiring decision making process. The applicant, by signing the application gives the employer consent to collect the information contained herein and use for the purpose specified.I authorize this company to investigate all statements contained on this application. I understand that any misrepresentationor omission of facts called for is cause for immediate disqualification and/or if employed, immediate dismissal.I understand that if I am hired, I will be required to provide a criminal background check at my cost, proof of identity and legalauthority to work in Canada, proof of certifications or educational qualifications, and a drivers abstract (if applicable).Furthermore, I understand and agree that if employed, I am free to resign at any time, with or without cause and withoutprior notice, and the employer reserves the same rights to terminate my employment at any time, with or without prior notice,except as may be required by law. This application does not in any way constitute an agreement or contract for employment.
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