Disclosure and Release of Information Authorization Personal Information



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Disclosure and Release of Information Authorization

Personal Information

Gender:


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First Name:





Middle Name:


☒None

Last Name:




Social Security Number:





Date of Birth:


mm/dd/yyyy

High School / GED / Adult Education Information

Diploma Type:


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Date Obtained:


mm/yyyy

Name Graduated Under:





Name of School/Testing Center:




City:





State:


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Other names you have used (maiden, AKA, etc.) at college/universities, vocational training, place of employment, etc.
Click "None" if not applicable

☐None


Highest Education Level

College or Technical School Name:





City:





State:


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Country:





Graduated?


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Dates Attended From:


mm/yyyy

Dates Attended To:


mm/yyyy

Degree Type:


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Major:





In connection with my application for employment, I understand that consumer reports, which contain public records information, may be requested from Henry Ford Health System as part of a background investigation on me. These reports may contain information concerning my employment, professional licenses, educational achievements, registrations and certifications, criminal records, motor vehicle reports, bankruptcy proceedings, etc. from federal, state and other agencies which maintain such records.

Further, I understand that an Investigative Consumer Report may be requested. These reports may include the following types of information: previous and current employment, reason for termination of employment, work experience, drugs/alcohol use, information relating to your character, general reputation, personal characteristics, mode of living, or any other information about you which may reflect upon your potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. I understand that this report may include confidential information related to my employment, education, character, and personal history.

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY HENRY FORD HEALTH SYSTEM OR THEIR AGENT, TO FURNISH THE ABOVE-MENTIONED INFORMATION OR ANY OTHER INFORMATION REQUESTED DEEMED PERTINENT TO MY EMPLOYMENT.

I hereby release any and all providers of above-mentioned information as well as any company/institution with whom they are or have been affiliated, from all liabilities, claims, or damages of any kind arising out of or related to the use, disclosure or release of that information, and unconditionally waive my right to assert any claims arising there from. I also release Henry Ford Health System and their respective officers, directors, employees, and agents from any or all liabilities, claims, damages, or losses arising out of or related to the use, disclosure, or release of information obtained.

In accordance with the FCRA and applicable state laws, I understand that I have the right to request a complete and accurate disclosure of the nature and scope of the investigation requested. Further, I am entitled to know if employment is denied because of information obtained by Henry Ford Health System. In the event that I am denied the position based entirely or partly on information obtained by Henry Ford Health System, I understand that I have the right to make a request to Henry Ford Health System, upon proper identification, to inquire on the nature and substance of all information in the files on me at the time of the request.

I understand that any consumer report and/or investigative consumer report requested will be used strictly for employment purposes, as a report to be used for the purpose of evaluation for employment, promotion, reassignment or retention as an employee. By signing below, I authorize Henry Ford Health System to obtain a consumer report and/or investigative consumer report on me as part of its pre-employment background investigation process. If I am offered employment by Henry Ford Health System, I further authorize Henry Ford Health System to obtain additional consumer/investigative consumer reports on me for employment purposes at any time during my employment.



Employer Contact

May we contact your current employer for a reference?

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If not, explain:



     

Residence Information

Have you used any other name(s) at current residence?

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If yes, please indicate:


     

Current Street Address:


     

Current City:


     

Current State:


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Since What Date:


mm/yyyy

Previous Residence 1 (If less than 7 years ago):

 

    



Previous Residence 2 (If less than 7 years ago):

    






Previous Residence 3 (If less than 7 years ago):

    






Previous Residence 4 (If less than 7 years ago):

   

   




Previous Residence 5 (If less than 7 years ago):

 

     






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