Applicant Authorization and Consent for Release of Information
Braun's Nursing Home, LLC requires, as a condition of employment, and/pr continued employment that all applicants consent to and authorize a verification of the information submitted on their application ro resume. Please read this statement carefully.
This release and authorization acknowledges that Braun's Nursing Home, LLC may now, or at any time while I am employed conduct a verification of my education, employment history, credit history, and motor vehicle records including accident history. In addition I understand that an Investigative Consumer Report may be request and I understand that this report may include information as to my character, general reputation, personal characteristics, mode of living, work habits, performance and experience, along with the reason for termination of past employment, whichever are applicable, obtained through personal interviews with associates and personal references who have knowledge concerning such items of information. In addition Braun's Nursing Home, LLC may request and receive any record of criminal history or other relevant information pertaining to me which may be in the files of any Federal, State or Local criminal justice agency, and/or other information as deemed necessary to fulfill the job requirements.
I have read and understand this release and consent and authorize the background verification. I authorize persons, schools, current and former employers, and other organizations and agencies providing such information from any and all claims of damages in connection to their release of any requested information. I agree that any copy of this document is as valid as the original.
I authorize Reference Services, Inc. and any of its agents and/or employees to disclose verbally and in writing the results of this verification process to the designated authorized representatives of Braun's Nursing Home, LLC. The results may be used to determine employment eligibility under this Company's employment policies.
I do hereby agree to forever release and discharge Braun's Nursing Home, LLC, its agents, Reference Services, Inc. its agents as well as any and all agencies providing such information to the full extent permitted by law from any claims, damages, losses, liabilities, cost and expenses, or any other charge or complaint filed with any agency arising from the retrieving and reporting of information. According to the Federal Fair Credit Reporting Act, I am entitled to know if employment was denied based on information obtained by my prospective employer, and to receive, upon request, a discloser of the public record information and of the nature and scope of the investigative report. If I am resident of Minnesota, California or Oklahoma only and would like a copy of the investigative report, I will check below.
I, the undersigned applicant, do hereby certify that the information provided by me for the purpose of employment is true and complete to the best of my knowledge. I understand that if I am employed, any false statements will be considered as cause for possible dismissal. I also acknowledge that any employment with Braun's Nursing Home, LLC is at will employment and either the company or the employee can terminate the employment relationship at any time, with or without cause, with or without notice.
Please provide all requested information and provide addresses for the last seven (7) years.