Background check authorization

Background check authorization
EMPLOYMENT BACKGROUND AUTHORIZATION

By signing below, the undersigned hereby authorizes TheraCare or its agents to obtain any and all information that pertains to my eligibility for employment. This information will include, but is not limited to, criminal records, credit history, employment verification, social security number verification. I also understand that the information below regarding sex, race and date of birth is requested for the sole purpose of gathering the above information correctly, and will not be used to discriminate against me in violation of any law.
Name

First NameMiddle NameLast Name
Please list all other names used:
Social Security Number
License Number
State of License
What is your discipline?

RNPTOTCNA
Is this a compact license?

YesNo
Date of Birth
Sex

MaleFemale
Race
Drivers License Number & State issued
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years at Residence
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years at Residence
I state that the information above is accurate to the best of my knowledge. I also understand that information about my background may contain negative information about my character and style of living. This releases any liability against the company or it's acting agents. This authorization may be used in copy form.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty: