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do hereby authorize verification of all information in my employment application from all sources, including employment, education, motor vehicle, financial history, criminal history, personal character, and workers’ compensation records, in accordance with ADA, labor, and wage laws. I authorize any duly authorized agent of IntelliCorp Records, Inc. to obtain these records, whether public or private, including those deemed privileged or confidential in nature. I release all persons from liability on account of such disclosures.
Information appearing on this authorization will be used exclusively by IntelliCorp Records, Inc. for identification purposes and to release information which will be considered in determining suitability for employment. I certify that I have provided true, correct, and complete answers and statements on my employment application, any supplements to it, and in any interview, knowing that they will be relied upon in considering my application for employment.
I agree to provide additional information that may be requested to process my employment application. I authorize, without reservation, any party or agency contacted by IntelliCorp Records, Inc. to furnish the above-mentioned information. This authorization is valid during the course of my employment to the extent permitted by law.
**I hereby
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authorize you to contact my current employer for employment and reference verifications.
(This will authorize immediate inquiries to the Human Resources Department and to any listed supervisors or references in the Employment/Reference section of your application.)
I have the right to make a request to IntelliCorp Records, Inc., upon proper identification, to obtain the nature and substance of all information in its files on me at the time of my request, including sources of information and the recipients of any reports on me that IntelliCorp Records, Inc. has previously furnished within the two-year period preceding my request.
I understand and agree that any omission, false statement, misleading statement, or answer made by me on my application, any supplements to it, or in any interviews may be sufficient grounds for rejection of employment or for discharge after employment.
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CALIFORNIA, OKLAHOMA, AND MINNESOTA RESIDENTS ONLY:
If you are a current California, Oklahoma, or Minnesota resident and would like to request a copy of your Consumer Report or Investigative Consumer Report, please check the box. This report may include character and reputation information obtained through personal interviews.
MASSACHUSETTS APPLICANTS ONLY:
Under Massachusetts law, an employer is prohibited from making written, pre-employment inquiries of an applicant about his or her criminal history. Massachusetts applicants should not respond to any of the questions seeking criminal record information.
DISCLAIMER:
This form is not intended to provide legal advice of any kind. Legal advice should be sought from your attorney. We make no claims, promises, or guarantees about the accuracy, completeness, or adequacy of the information contained herein. We make no warranty that this form is appropriate for your particular needs.
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Name Check Access
I authorize the North Carolina Department of Public Safety, through the State Bureau of Investigation, to perform a North Carolina name-based criminal history record information check in connection with my application for employment, or my employment or volunteer services with A1-Omega Healthcare Services, pursuant to DHHS—Long Term—State and Federal NCGS 122C-80B / 131D-40A A1 / 131D-40A A1.
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I understand that the North Carolina State Bureau of Investigation, its officials, and employees shall not be held legally accountable in any way for providing this information to the above-named agency, and I hereby release said agency and persons from any and all liability that may be incurred as a result of furnishing such information. I further understand that the above-named agency cannot provide a hard copy of the results of this criminal history record check to me.
Disclosure of your Social Security number is entirely voluntary and not required. If disclosed, the Social Security number will be used solely to assist with accurate identification and exclusion of possible criminal history records.
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