Informed Consent Authorization for Employment Purposes

I hereby give Divine Home Care, Inc., the right to make a thorough investigation of my past employment, education, and activities. I release from all liability, Divine Home Care, Inc., et al and/or its agents to retrieve information from any/all government agencies, social services agencies and law enforcement agencies, to supply any and all information concerning my background, and release the same from any liability resulting in providing such information. Divine Home Care, Inc., does not run credit reports, but is required to conduct criminal conviction searches in hiring process. I understand that I am required to pass a criminal background check by the Department of Human Services and understand that if for any reason I would be disqualified, Divine Home Care cannot proceed with my employment.

I understand if my application for employment is granted, Divine Home Care, Inc., et al may obtain further information through subsequent investigations by a consumer reporting agency so as to evaluate me in regard to promotion, reassignment, retention, and to comply with operating license and/ or liability insurance requirements and/or applicable state/federal laws. This includes initial and annual criminal conviction searches, as well as investigations resulting from possible employee misconduct, negligence and /or incidences/accidents involving my employment and/or Divine Home Care, Inc., et al clients, “consumers”, agents, or assigns. This document is valid through out the course of my employment.

I understand that the disclosure of a criminal record will not automatically disqualify me from employment consideration and that my case will be judged on its merits. However, I understand that any false answers or statements or implications made by me in any application or other required documents, or acts of willful misconduct pertaining to my employment shall be considered sufficient cause for denial or employment discharge.

In order to verify my identity for purpose of background investigation and for obtaining certain consumer reports (i.e. criminal conviction record); I am voluntarily releasing my date of birth and fully understand that is not a consideration for employment.

I hereby release any individual or institution, including its officers, employees or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at the time result to me, because of compliance with this authorization and request to release information or any attempt to comply with it.

I understand that a consumer and/or investigative consumer report for the purpose of employment may be obtained. By checking the box below, the consumer reporting agency and/or Divine Home Care, Inc., et al will mail me a copy.

MN Residence Only
- I would like a copy of any consumer report regarding me.
- I would not like a copy of any consumer report regarding me.
Name
FirstLast
Previous Name/Maiden Name
Date of Change
MM
DD
YYYY
Aliases Known By
Address
Street AddressAddress Line 2CityStateZip Code
No P.O. Boxes
Date of Birth
MM
DD
YYYY
Age is not a consideration of employment
Social Security Number
Driver's License Number
State of License
Have you lived in any othe state in the past 7 years?
- Yes
- No
If yes, what year did you move to this state?
If yes, indicate which state(s) you previously resided in during that time
(In order - from most current)
I am willing that a photo copy of this consent form be accepted with the same authority as the original
Signature Phone Number Date

PDF

Informed Consent Authorization for Employment Purposes

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