Background Check Release Form Survey

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LAST NAME (PLEASE INCLUDE Jr., Sr., II, III etc.)*
MIDDLE NAME

Last Name
First Name
Middle Name

I understand that in conjunction with my application for employment, St. Catherine’s Nursing Center may use the services of an outside agency to research and verify the information I have provided on my application for employment including my personal background, character, professional standing, work history and qualifications. This agency will provide a written report of its findings to St. Catherine’s Nursing Center. St. Catherine’s Nursing Center will use Evolution Consulting LLC as an agent to perform its employment related background investigations.

Evolution Consulting LLC may utilize various sources of information it deems appropriate including but not limited to: credit reporting agencies, Workers Compensation records including any and all injuries in compliance with the Federal ADA Act, Department of Motor Vehicle records, criminal conviction records, current and former employers, military records, education records, professional and personal references. I request, authorize and consent to the release and disclosure of any and all information including but not limited to the above to, St. Catherine’s Nursing Center and Evolution Consulting LLC.

I request, authorize and consent to the procurement of an Investigative Consumer Report and/or Consumer Credit Report and understand that they may contain information about my background, mode of living, character, personal characteristics and general reputation. This authorization in original or copy form shall be valid for one year from the date indicated next to my signature. According to the Fair Credit Reporting Act, I will be notified by St. Catherine’s Nursing Center if employment is denied because of information obtained from a Consumer Reporting Agency. Additionally, I understand that if requested within 60 days, I will be given a full and accurate disclosure as to the nature and substance of all information provided to:

Law enforcement agencies and other entities for positive identification purposes require the following information when checking public records. It is confidential and will not be used for any other purposes. I hereby release St. Catherine’s Nursing Center and Evolution Consulting LLC, its agents and all persons, agencies and entities providing information or reports about me from any liability arising out of the request for or release of any of the above mentioned information or reports. This disclosure further serves as a request that any present or former employer, police department, educational or financial institution or other person having personal knowledge about me to furnish Evolution Consulting LLC and its affiliates or representative any and all information in their possession regarding me in connection with my application for employment. A photocopy/facsimile of this authorization may be accepted with the same authority as the original and I specifically waive any written notice from any present or former employer who may provide information based upon this authorized request.*

Typed Name:
Date:

Name*

First Name
Middle Name
Last Name

Other Names Used:

Maiden Name If Applicable
Other names you have used or are also known as

5.	Social Security Number*

Driver's License Information

Driver's License Number:
State of Issuance:
*Date of Birth:

Current Address*

Street and Number
City
State
Zip Code