Volunteer Application – Hospice

List two personal references: (do not include relatives; we prefer clergy or former employers)

Acknowledgement and Authorization

I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and the SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT AND REPORTING ACT and certify that I have read and understand both. I hereby authorize the obtaining of "consumer reports" and investigative reports" at any time after receipt of this authorization and, if I am contacted for employment, throughout the term of my contract. 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 any consumer reporting agency acting on behalf of the company. I certify that the information provided is true and complete to the best of my knowledge and agree that a facsimile ("fax") or photocopy of this authorization shall be valid as the original.

Notice Regarding Background Investigation

Please read Carefully Before Signing Acknowledgement In conjunction with your application for employment, the company may obtain information about you from ADP Screening Services. Thus, you may be subject to “consumer reports” and “investigative reports” which may include information about your character, general reputation, personal characteristics and mode of living, and which can involve personal interviews with sources such as neighbors, friends, or associates. Reports may also contain public records (including criminal records), eviction records, driving history information, consumer credit, employment and education verification, etc. These reports may be obtained at any time after receipt of your authorization and throughout the term of any employment. You have the right, upon written request made after receipt of this notice, to request disclosure of the nature and scope of an investigative report.

Certification

(Please read before signing) I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal and otherwise, the investigation of any criminal records, and release all parties form all liability for any damage that may result from furnishing same to you.