Legacy Home Health Care Background Screening Reports Release Form

In connection with my application for employment, I understand that consumer reports or investigative consumer reports which may contain public record information may be requested or made on me including criminal record social security number verification, motor vehicle/driving record, education verification, employment history, credit history or other background checks. The applicant may be required to provide a set of the applicant's fingerprint impressions as part of this criminal records check. I understand that I have the right ,upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report.

I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by any outside organization acting on behalf of the Company, and or the Company itself. I also agree that a fax or photocopy of this authorization with my signature be accepted with the same authority as the original. I further authorize ongoing procurement of the above-mentioned reports at any time during my employment (or contract).

I understand that I have the right to make a written request of First Advantage Background Services Group, PO Box 105108 Atlanta, GA 30348-5108, 800-845-6004; Certiphi Screening, Inc., PO Box 541, Southhampton, PA 18966, 800-260-1680; or Fowlers' Profile Links, Inc., PO Box 291043 Nashville, TN 37229, 866-887-7581 upon porper identificationa nd the payment of authorized fees, fo rthe information its files on me at the time of my request. The agency to which you have made your employment application, can advise you of the proper organization.