Form - Background Check Authorization - HomeCentris Healthcare

Applicant Name: *

In which state do you work?

Maryland

Virginia

Pennsylvania

Authorization

I authorize HomeCentris Healthcare, LLC together with its subsidiaries, affiliated companies, successors, and assigns to which employee provides services, if any (collectively “COMPANY”) to order my consumer report (background check). I understand that, as allowed by law, the Company may rely on this authorization to order additional reports without asking me for my authorization again (1) during my employment, and (2) from any consumer reporting agency (“CRA”). A copy of this original in hard copy, electronic, faxed, or electronically signed form shall be as valid as the original.

For the purpose of preparing a consumer report (background check) for the Company, and only for that purpose, and subject to all laws protecting my informational privacy, I also authorize the following to disclose to the consumer reporting agency the information needed to compile the report: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; all courts; the military; other CRAs; testing facilities; and all motor vehicle records agencies. I acknowledge the information that can be disclosed to the consumer reporting agency, as allowed by law, includes information concerning my employment and earnings history, education, motor vehicle history, criminal history, military service, and professional credentials and licenses.

Additional information about your rights has been provided to you with this Background Check Authorization Document. Please review it BEFORE you sign.

Date *

Email Address: We will email you a copy. *

Signature *

Clear