(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.)
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.
Give three references, not relatives or former employees
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
BACKGROUND CHECK AUTHORIZATION
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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