Background Check Authorization Form | Golden Grace Health Care LLC

Applicant information

Full Name *Other Names Used (if any)Date of BirthSocial Security Number (last 4 digits only)Your full number is collected securely in person.Driver’s License NumberState of IssueCurrent AddressCityStateZip CodePrevious Address (if less than 3 years at current)CityStateZip Code

Authorization and Disclosure

I hereby authorize Golden Grace Health Care LLC to obtain a background check and/or investigative consumer report, including but not limited to, information concerning my criminal history, motor vehicle records, education, employment history, and any other relevant information for employment purposes.

I understand that this report may include information regarding my character, general reputation, personal characteristics, and mode of living.

This authorization shall remain on file and shall serve as ongoing authorization for Golden Grace Health Care LLC to procure such reports at any time during my employment.

Acknowledgment and Signature

I certify that the information provided on this form is true and correct. I understand that false statements or omissions may result in denial of employment or dismissal if already employed.

I certify and authorize as stated above

Signature of Applicant *

By signing, you agree this electronic signature is the legal equivalent of your handwritten signature.

Date

Parent/Guardian Signature (if under 18)

By signing, you agree this electronic signature is the legal equivalent of your handwritten signature.

Date

Office Use Only — Date Received · Reviewed By · Date Background Check Requested · Results: Clear / Follow-up Required · Notes (completed by Golden Grace staff).