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Application and Background Disclosure Form

Pursuant to the requirements of the Fair Credit Reporting Act, notice is given that a consumer report* may be made in connection with your application for employment. If you are denied employment, either wholly or partly, because of information contained in a consumer report, a disclosure will be made to you of the name and address of the consumer reporting agency making such report. You will also receive a copy of the report and a statement of your consumer rights.

By signing below you consent to the procurement of a consumer report* in connection with your application for employment and/or continued employment.

General Information

Applicant's Name: _______________________________________________________________

Applicant's Other Last Names Used: _________________________________________________

Address(No P.O. boxes)___________________________________________________________

City __________________________State:_________________ Zip ________________________

Security Number: _________-_________-__________ Date of Birth: _______/________/________

Driver’s License No. _______________________________________________ State: _________

Education Verification:

College/University:_______________________________ City:__________________ State:______

Degree:___________________________________ Graduation Date:______/________/________

List all of the cities (including state and county) lived in for the last SEVEN YEARS.

*A consumer report may consist of employment records, educational verification, licensure verification, driving history, previous addresses, and other public records relative to criminal charges. A credit report will not be requested unless it is deemed pertinent to the functions of the position for which you are applying.

BACKGROUND VERIFICATION DISCLOSURE

As part of the employment process, Driscoll Children’s Hospital (DCH) has chosen to obtain a form of consumer report, a criminal record check and GSA Debarred list and/or DHSS Cumulative Sanctions list, on applicants for employment, and a motor vehicle record check on applicants whose employment would require driving. These checks are performed under the federal Fair Credit Reporting Act to ensure a safe working environment. Additionally, DCH may conduct further criminal record and motor vehicle record checks or obtain other consumer reports, including investigative consumer reports that include information as to your character, general reputation, personal characteristics, and mode of living, at certain times during employment, such as when employees are evaluated, or when employees apply for transfer or promotion. If an investigative consumer report is prepared, you have the right to request in writing complete and accurate disclosure of the nature and scope of the information requested and a summary of your rights as a consumer under the Fair Credit Reporting Act.

AUTHORIZATION AND RELEASE

I acknowledge receipt of this notice and authorize DCH and its agents to obtain consumer reports on me, including criminal record, GSA Debarred list and/or DHHS Cumulative Sanctions list, and motor vehicle record checks or investigative consumer reports that may include information as to my character, general reputation, personal characteristics, and mode of living, for employment purposes at any time during my employment or as part of DCH’s pre-employment background investigation. I understand that this consumer report will be obtained under the federal Fair Credit Reporting Act and will be used to determine my suitability for employment.

I understand that DCH requires me to consent to the consumer report and provide certain identifying information to facilitate the record check process as a condition of employment. I also understand that failure to consent to credit, criminal record or motor vehicle record checks or other consumer reports, including investigative consumer reports, will result in ineligibility for employment or termination of employment.

I authorize any person, organization, governmental authority, or other party to release and disclose information and cooperate in the obtaining and producing of consumer reports on me. If I am hired, this authorization shall remain valid and shall serve as an ongoing authorization for DCH and its agents to obtain consumer reports on me, including criminal record and motor vehicle record checks, for employment purposes at any time during my employment. I understand that if an investigative consumer report is prepared, I have the right to request in writing complete and accurate disclosure of the nature and scope of the information requested and a summary of my rights as a consumer under the Fair Credit Reporting Act.