Sunbridge Background Check Authorization

Sunbridge Background Check Authorization

Please note that a background check is required for all Sunbridge field staff. To allow us to complete this process, please carefully fill out all required fields and complete the questionnaire in its entirety. Incomplete information may delay your onboarding.
First Name*
Middle Name*
Last Name*
Former Names Used*
If more than one, please separate with a comma. Please put N/A if there is not a former name you use.
Address*

Street Address Line 1

Street Address Line 2.

CityStateProvince

Zip Code
Living at Current Address Since*
Please provide month and year
Previous Address You Lived At Prior To Current Address:
Address*

Street Address Line 1

Street Address Line 2.

CityStateProvince

Zip Code
Beginning Date lived at Previous Address*
Please provide month and year
End Date lived at Previous Address*
Please provide month and year
Social Security Number*
9 digits
Date of Birth*

MonthDayYear
Date
Drivers License Number*
State of Drivers License*
Please Provide a Photo of the Front of your Driver's License (Please note that you do not need to upload if you have already done so in the "HR Required Forms" section)

Cancelof
I have been convicted of a felony or have been convicted as a sexual offender.I have been convicted of any misdemeanor in the last 5 years.I have special circumstances, questions, or would like to discuss my situation with a company representative.I have none of the above.
The information contained in this application is correct to the best of my knowledge.

I hereby authorize Sunbridge Home Health Care and its designated agents andrepresentatives to conduct a comprehensive review of my background causing aconsumer report and/or an investigative consumer report to be generated for employmentand/or volunteer purposes. I understand that the scope of the consumerreport/investigative consumer report may include, but is not limited to the following areas:verification of social security number; credit reports, current and previous residences;employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, countyjurisdictions; driving records, birth records, and any other public records.

I further authorize any individual, company, firm, corporation, or public agency to divulgeany and all information, verbal or written, pertaining to me, to Sunbridge Home HealthCare or its agents. I further authorize the complete release of any records or datapertaining to me which the individual, company, firm, corporation, or public agency mayhave, to include information or data received from other sources.Sunbridge Home Health Care and its designated agents and representatives shallmaintain all information received from this authorization in a confidential manner in orderto protect the applicant’s personal information, including, but not limited to, addresses,social security numbers, and dates of birth.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: