* Required Information
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize and request any law enforcement agency to furnish bearer with criminal history and identity check information in their possession regarding me in connection with my employment in a critical position. I am willing that a photocopy of this authorization be accepted with the same authority as the original. I understand that the positions that are designated critical require background checks for the purpose of evaluating me for employment, promotion, reassignment, reclassification, transfer, or retention as an employee. I also understand that any misrepresentation, falsification or omission of facts herein may be grounds for disqualification. Release or dismissal.
Driver's License Information
Current Address

Complete the Driver's License information only if this position requires that you drive a motor vehicle

Driver's License Information
Privacy Notice
The principal notice for requesting the information on this form is to conduct background checks on individuals selected for critical positions. Our policy and federal statute authorize the maintenance of this information.
Furnishing all information requested on this form is mandatory. Failure to provide such information shall result in a determination that the applicant is eligible for employment or not appropriate for reassignment.

I hereby certify that all statements on this application are true and correct to the best of my knowledge and belief. I understand that Neighbors Keeper Home Health solicits this information so as to be informed of my previous record and character. I understand that my employment with Neighbors Keeper Home Health depends upon successful completion of a criminal background investigation. If employed, I understand that any falsification, misrepresentation of omission of facts of this record may be considered cause for release dismissal.

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