PRE-EMPLOYMENT BACKGROUND CHECK AUTHORIZATION

PRE-EMPLOYMENT BACKGROUND CHECK AUTHORIZATION
PRE-EMPLOYMENT BACKGROUND CHECK AUTHORIZATION

I understand that as part of the employment process, Bourke Home Care 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 Bourke Home Care 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 Bourke Home Care is contingent upon successful completion of a background check.
Signature

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Date

MonthDayYear
Date
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
SSN
Date of Birth

MonthDayYear
Date
Current Driver’s License
State
List any other cities, states and dates of residency during the last 10 years
Application for Employment
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referred to us by
Position(s) applied for
Date available
Type of employment desired

Full TimePart TimeWeekends
If currently employed, may we contact your employer?
Rate of Pay Expected
Is there a specific reason you are applying for employment at this company?
If Yes, please briefly outline the reason:
Are you legally eligible for employment in this country?
Are you available to work overtime if required?
Have you applied with this company before?
If yes, when?and at what location?
Have you been convicted of a crime in the last seven (7) years?
If yes, please explain
If considered for hiring, will you agree to provide a criminal background check?
If considered for hiring, will you agree to provide a driver's abstract?
EDUCATIONAL BACKGROUND
SCHOOL:   Type a label
CITY, STATE/PROVINCE:   Street Address   Address Line 2   City   State   Zip
GRADUATED?:     Yes   No
DEGREE(s)/DIPLOMA(s) EARNED:   Type a label

SCHOOL:
CITY, STATE/PROVINCE:
GRADUATED?:
DEGREE(s)/DIPLOMA(s) EARNED:

SCHOOL:   Type a label
CITY, STATE/PROVINCE:   Street Address   Address Line 2   City   State   Zip
GRADUATED?:     Yes   No
DEGREE(s)/DIPLOMA(s) EARNED:   Type a label
What Nursing or relevant designations, licenses or registrations if any, do you possess?

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

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

Type:   Type a label
Date of Most Recent Registration:   Date
Valid in State/Province ?:     Type a label
Do you have the following:

CPR:   Yes   No
Last Certified:   Date
First Aid:   Yes   No
Last Certified:    Date
WHMIS:   Yes   No
Last Certified:    Date
PLEASE ANSWER THE FOLLOWING QUESTIONS
What do you think is the most difficult part of nursing or customer service work?
What was the best job you ever had and why?
What was your least favorite job and what did you dislike about it?
Think of the BEST supervisor you have ever had, what characteristics made that person a good manager?
Think of the WORST supervisor you have ever had, what characteristics made that person a poor manager?
How will you be able to contribute to providing seniors with high quality care?
Imagine you have been on your feet and working hard all day. A customer that you have been dealing with is rude and impatient, what do you do?
EMPLOYMENT BACKGROUND

Provide the following information beginning with the most recent employer.
EMPLOYER:   Type a label
TELEPHONE:   Area Code   Phone Number
DATES EMPLOYED:
FROM:   Date         TO:    Date
HOURLY RATE/SALARY:   Type a label
JOB TITLE:   Type a label
IMMEDIATE SUPERVISOR NAME:   Type a label
REASON FOR LEAVING:     Type a label
MAY WE CONTACT FOR REFERENCE?:   Type a label

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

EMPLOYER:   Type a label
TELEPHONE:   Area Code   Phone Number
DATES EMPLOYED:
FROM:   Date         TO:    Date
HOURLY RATE/SALARY:   Type a label
JOB TITLE:   Type a label
IMMEDIATE SUPERVISOR NAME:   Type a label
REASON FOR LEAVING:     Type a label
MAY WE CONTACT FOR REFERENCE?:   Type a label
REFERENCES

List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please).
NAME:   First Name   Last Name
RELATIONSHIP:    Type a label
YEARS ACQUAINTED:   Type a label
PHONE NUMBER:     Area Code   Phone Number

NAME:
RELATIONSHIP:
YEARS ACQUAINTED:
PHONE NUMBER:

NAME:   First Name   Last Name
RELATIONSHIP:    Type a label
YEARS ACQUAINTED:   Type a label
PHONE NUMBER:     Area Code   Phone Number
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 misrepresentation or 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 legal authority 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 without prior 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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PRE-EMPLOYMENT BACKGROUND CHECK AUTHORIZATION

PRE-EMPLOYMENT BACKGROUND CHECK AUTHORIZATION

Application for Employment

EDUCATIONAL BACKGROUND

PLEASE ANSWER THE FOLLOWING QUESTIONS

EMPLOYMENT BACKGROUND

REFERENCES