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Disclosure And Authorization

BACKGROUND INVESTIGATION QUESTIONNAIRE:

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PERSONAL INFORMATION:


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CURRENT RESIDENTIAL ADDRESS:


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DRIVER'S LICENSE INFORMATION:


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PREVIOUS RESIDENTIAL ADDRESS


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COURT HISTORY


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YesNo

YesNo

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IMPORTANT – PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION

DISCLOSURE REGARDING BACKGROUND INVESTIGATION
Shalom Community Care, Inc. may obtain information about you from a consumer reporting agency for Employment purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment history, or other background checks. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants as a tenant is an investigation into your education and/or employment history conducted by Fowlers' Profile Links, Inc., PO Box 291043, Nashville, TN, 37229, 1-866-887-7581 or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing Shalom Community Care, Inc to obtain from any outside organization all manners of consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

New York applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by Mighty Hearts Home Care, Inc. by contacting the consumer reporting agency identified above directly.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT 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” by the Company at any time after receipt of this authorization and throughout my employment, if applicable. 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, or insurance company to furnish any and all background information requested by Fowlers' Profile Links, Inc., PO Box 291043, Nashville, TN, 37229, 1-866-887-7581 another outside organization acting on behalf of Shalom Community Care, Inc, and/or Shalom Community Care, Inc, itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company. □

California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law. □

NOTICE: Fowlers’ Profile Links, Inc. requests your Date of Birth solely for the purpose of verifying certain records that may be produced in connection with Fowlers’ Profile Links, Inc. background investigation. It is the policy of this facility to provide equal opportunity to persons regardless of race, religion, age, gender, disability or any other classification in accordance with federal, state and local statutes, regulations and ordinances.

I, hereby verify with my e-signature below that, according to my knowledge, I have fully and truthfully supplied all requested and required information.

Shalom Community Care

2201 Murfreesboro Pike
Suite A-222
Nashville, TN 37217
Phone: +1 615 678-5041
Fax: +1 615 457-1193
[email protected]

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