Background Check Cost Reimbursement Acknowledgement and Payroll Deduction Authorization
Please review the agreement below and complete all required fields.
Agreement: Background Check Cost Reimbursement Policy
Background Check Reimbursement Policy:
Harmony Heights Home Health Services LLC requires all applicants to undergo a background check as a condition of employment. The cost of the background check will be reimbursed to the company through payroll deduction.
Payroll Deduction Authorization:
By signing below, you authorize Harmony Heights Home Health Services LLC to deduct $20.00 per paycheck from your wages until the total cost of the background check has been reimbursed.
Employee Rights:
You have the right to request documentation regarding the cost of the background check and the amount deducted from your paycheck at any time.
Certification and Authorization:
By completing and signing this form, you acknowledge that you have read and understand the above policy and voluntarily authorize the payroll deduction as described.
Employee Name - First
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Employee Name - Last
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Position
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Date of Hire
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employee Signature
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Employee Signature Date
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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