* Required Information
Application For Employment

(A yes answer does not automatically disqualify you from employment, since the nature of the offense, date, and the job for which you are applying will also be considered.)

For Driving Jobs Only

List names of employees in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references. PLEASE GIVE MONTH AND YEAR.

Dates of Employment
Pay
Dates of Employment
Pay
Dates of Employment
Pay

Give three references, not relatives or former employees

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING
I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.
I understand that the employer may request an investigative consume report from a consumer reporting agency and I must pass the background screening AHCA fingerprinting in order to work & be considered for employment. This report may include information as to my character, reputation, personal characteristics and made of living obtained from interviews with neighbors, friends, former employers, schools and others. I understand I have a right to make a written request within a reasonable time for the disclosure of the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation.
I authorize the investigation of any of all statements contained in this application and also authorize any person, school, current employer (except as previously noted) past employers and organizations named this application to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organization from any legal liability in making such statements.
I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be required to successfully pass a drug screening examination. I hereby consent to a pre and/or post-employment drug screen as a condition of employment, if required.
I understand that this application or subsequent employment does not create a contract of employment nor guarantee employment for any definite period of time, if employed, I understand and that I have been hired at the will of the employer and my employment may be terminated at any time, with or without cause and with or without notice. I have read, understand, and by my signature consent to these statements.

EMPLOYEE AVAILABILITY

Please provide the following information on your availability to work for MedicalOne Health.

Please Check (X) the Day and Time of Week You Are Available

TELEPHONE REFERENCE CHECK FORM - NUMBER 1

I authorize the company I worked for and/or the individual listed above to release information about me to MedicalOne Health LLC.

INTERVIEWER: Introduce yourself, identify our company) “One of your former employees, (name), has applied for employment at our company as a (job title). Hopefully, you will give me some insight on (him/her) and whether this is a suitable position for (him/her). May I ask you a few questions?”

TELEPHONE REFERENCE CHECK FORM - NUMBER 2

I authorize the company I worked for and/or the individual listed above to release information about me to MedicalOne Health LLC.

INTERVIEWER: Introduce yourself, identify our company) “One of your former employees, (name), has applied for employment at our company as a (job title). Hopefully, you will give me some insight on (him/her) and whether this is a suitable position for (him/her). May I ask you a few questions?”

BACKGROUND CHECK AUTHORIZATION

APPLICANT: Complete the following information as accurately as possible. (Please Print Clearly.)
Addresses: (List past seven years beginning with your current address. Include street, city, state, zip code, county and dates of residence. Attach additional sheet, if necessary.)

ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK

I acknowledge receipt of the FCRA required documents DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT which are both available at https://www.trudiligence.com/downloadforms.php and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, workers compensation bureau, testing laboratory or insurance company to furnish any and all background information requested by TruDiligence, LLC, 3190 S Wadsworth Blvd, Suite 260, Lakewood, CO 80227, 800-580-0474, or another outside organization acting on behalf of Employer, and/or Employer itself. I understand that these files may contain negative information about my background, mode of living, character and personal reputation; therefore, I agree to defend and hold harmless TruDiligence and any agent acting on its behalf, from any and all liability arising through the investigation of my background. If applicable, I hereby authorize the release of my confidential report to any Third Party directly involved in the hiring or placement process and understand that any release to a third party will not occur until that party has completed a certification regarding the use and viewing of confidential information. I agree to release, hold harmless, and indemnify TruDiligence from any liability, claims, demands, causes of action, damages, or expenses resulting from: any release of information to the Third Party pursuant to this authorization; the unauthorized use of this information by the Third Party; and, any actions taken by the Third Party pursuant to this authorization.

I understand that my date of birth is used solely as an identifier to avoid possible misidentification while completing the background check process. I agree that a facsimile (“fax”), electronic, or photographic copy of this Authorization shall be as valid as the original.

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