ADP TOTALSOURCE. BACKGROUND CHECK AUTHORIZATION. I hereby state that the information given by me in my employment applic
ADP TOTALSOURCE BACKGROUND CHECK AUTHORIZATION I hereby state that the information given by me in my employment application, in interviews, or by any other means is true and complete in all respects, and I agree that if any information is found to be false or incomplete in any respect, I will be subject to rejection of my application or termination of my employment and benefits. I give permission for an investigation to be conducted now or at any time during my employment, which may include inquiries regarding my past employment, education, criminal, credit, driving record and worker’s compensation history. I authorize past employers, personal references and any other persons or organizations who maintain this information to provide it upon receipt of this authorization, and I release all such persons and organizations from any liabilities or damages on account of having furnished such information in good faith. I specifically authorize the release of any criminal history information, which may be in the files of any state or local criminal justice agency. Should I become employed, I authorize the employer named herein to answer such questions for the benefit of future employers conducting similar investigations. I understand that I an entitled to a statement of my rights under the Fair Credit Reporting Act. I understand that the information below regarding sex, race and date of birth is requested for the sole purpose of gathering the above information accurately, and will not be used to discriminate against me in violation of any law. A telephonic facsimile (FAX) or photographic copy of this authorization shall be as valid as the original.
Full Name (no nicknames): ___________________________________________________________ Other Names (i.e., maiden, nicknames, alias):_____________________________________________ Social Security #:____________________Date of birth: ___________Race: __________Sex: ______ Driver’s License Number ___________________________________State Issued: _______________ # of Years as a resident of North Carolina ____________ List below all addresses for last SEVEN years starting with most current: (attach additional page if necessary) Street City State Zip County Dates 1. ________________________________________________________________________________ 2. ________________________________________________________________________________ 3. ________________________________________________________________________________ 4. ________________________________________________________________________________ 5. ________________________________________________________________________________ _______________________________________________ Applicant’s Signature
_____________________________ Date
ORDERS VARY ACCORDING TO REQUEST Client Name (needed for itemized billing): __Aston Park Health Care Center, Inc.______________________Company Code______ Request Submitted By: __________________________________________________
Today’s Date: ______________________________
A CRIMINAL HISTORY SEARCH WILL BE FOR A 7 YEAR PERIOD BY JURISDICTION *If less than a 7 year criminal history is desired, please circle only those numbers corresponding to the addresses above which you want checked : 1 2 3 4 5 For other items check here: CRIMINAL: (Please check one, two or all three ) FEDERAL:_____ STATEWIDE: _____ COUNTY: _____ CREDIT:_____MVR_______CREDENTIAL VERIFICATION______ EMPLOYMENT VERIFICATION*: _____ EDUCATION VERIFICATION*: _____ *Please include employment application when ordering these items Fax this form to Jacklyn Ruiz ADP/TotalSource @ 770-751-3192. If you have any questions call ADP/TotalSource @ 888-220-6055 RETURN RESULTS BY FAX TO: ________________________________ @ FAX #: _______________________ Phone # ____________________
