Form - Background Check Disclosure - HomeCentris Healthcare

Background Check Disclosure

Applicant Name: *

In which state do you work?

Maryland

Virginia

Pennsylvania

Authorization

HomeCentris Healthcare, LLC together with its subsidiaries, affiliated companies, successors, and assigns to which employee provides services, if any (collectively “COMPANY”) may order a “consumer report” (commonly known as “background report” or “background check”) on you in connection with your employment application, and if you are hired, or if you already work for the Company, may order additional background reports on you for employment purposes.  

To the extent allowed by law, the background report may contain information concerning your character, general reputation, personal characteristics, mode of living, drug and alcohol test results, and criminal history.  To the extent allowed by law, information may be obtained from private and public record sources, including but not limited to, sanctions databases, court records, driving records, verification of employment and education history, licensing and credentials, military records, and police records.

Date *

Email Address: We will email you a signed copy. *

Signature *

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