ACKNOWLEDGEMENT AND CONSENT OF DRUG TESTING
I, _____________________________________, understand and acknowledge that as a condition
of employment as a HealthCare Staffing, Inc. employee, or as a condition of continuing
employment a HealthCare Staffing, Inc. employee, I must take and pass a drug test. I further
understand if the drug test indicates the presence of unlawful drugs in my system, I will be
ineligible to work and I will be terminated from my employment with HealthCare Staffing, Inc. I also
understand that during an assignment, a client facility may require that I consent to a random drug
test in accordance with their policies and procedures. I hereby agree that I will abide by the
facility’s policies and procedures and will consent to a drug test if required and authorize the facility
to release the results of the drug test to HCS.
Fully aware of the above, I consent to submit to drug testing. I authorize any laboratory or medical
provider chosen by HealthCare Staffing, Inc. to perform such drug test and release results to HCS
directly. I further authorize HealthCare Staffing, Inc. to release results of the drug test to facilities
as may be required to obtain assignment.
I release any legal claim I may have against HealthCare Staffing, Inc., its officers, agents and
employees for requiring a drug test, and for any adverse employment action taken as a
consequence of the test and/or results.
_______________________________
Name Printed
_______________________________ ______________________________
Signature Date
________________________________ ______________________________
Witnessed By Date
FAX TO: 888-454-7679
CLIENT NAME: Healthcare Staffing Incorporated CLIENT ACCOUNT NUMBER: 852609
CLIENT CONTACT: PHONE NUMBER:
NOTICE REGARDING BACKGROUND INVESTIGATION
NOTICE AND ACKNOWLEDGMENT
[IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING ACKNOWLEDGMENT]
Healthcare Staffing Incorporated 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 include employment history and reference checks,
criminal and civil litigation history information, motor vehicle records (“driving records”), sex offender status, credit reports, education verification, professional licensure, drug testing,
Social Security Verification, and information concerning workers’ compensation claims (only once a conditional offer of employment has been made). 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 for employment is an investigation into your education and/or
employment history conducted by Employment Screening Services, 1401 Providence Park Birmingham, AL 35242, toll-free 866.859.0143 or another outside organization. The
scope of this notice and authorization is all-encompassing; however, allowing Healthcare Staffing Incorporated to obtain from any outside organization all manner of consumer
reports and investigative consumer reports now and, if you are hired, 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.
ACKNOWLEDGMENT AND AUTHORIZATION
I acknowledge receipt of the NOTICE 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” 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, or insurance company to furnish any and all background information
requested by ESS, another outside organization acting on behalf of Healthcare Staffing IncorporatedI agree that a facsimile (“fax”), electronic or photographic copy of this
Authorization shall be as valid as the original.
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 if one is obtained by the Company at
no charge whenever you have a right to receive such a copy under California law. □
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. □
New York applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by Employer by contacting the
consumer reporting agency identified above directly.
___________________________________________________________________ _________________________________________
Signature of Employee or Prospective Employee Date
APPLICANT INFORMATION: TO BE COMPLETED BY APPLICANT
The following is for identification purposes only to perform the background check and will not be used for any other purpose: PLEASE USE BLACK INK.
_____________________________________________________________________ ___ _____________________________________________________________
Print: Last Name First Name Middle Initial Social Security Number
___________________ __________________________________________ _____________________________________________________________
Date of Birth Drivers License Number State Professional License Number State Type
____________________________________________________________________________________________________________________________________________
Current Address: City State Zip Code
____________________________________________________________________________________________________________________________________________
Previous Address (Past 7 Years): City State Zip Code
____________________________________________________________________________________________________________________________________________
Alias Names (Other names I have been known by):
_________________________________________ _______________ ______________________________ ________________________________
Degree Obtained Year Graduated Name of School City and State of School
10/07
SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT
Para informacion en espanol, visite www.ftc.gov/credit o escribe a la FTC Consumer Response Center, Room
130-A 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.
The federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of
information in the files of consumer reporting agencies. There are many types of consumer reporting
agencies, including credit bureaus and specialty agencies (such as agencies that sell information about
check writing histories, medical records, and rental history records.) Here is a summary of your major rights
under the FCRA. For more information, including information about additional rights, go to
www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600
Pennsylvania Ave. N.W., Washington, D.C. 20580.
You must be told if information in your file has been used against you. Anyone
who uses a credit report or another type of consumer report to deny your application for credit,
insurance, or employment – or to take adverse action against you- must tell you, and must give
you the name, address and phone number of the agency that provided the information.
You have the right to know what is in your file. You may request and obtain all
the information about you in the files of a consumer reporting agency (your “file disclosure”). You
will be required to provide proper identification, which may include your Social Security number.
In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
a person has taken adverse action against you because of information in your credit report;
you are the victim of identify theft and place a fraud alert in your file;
your file contains inaccurate information as a result of fraud;
you are on public assistance;
you are unemployed but expect to apply for employment within 60 days.
In addition, all consumers are entitled to one free disclosure every twelve (12) months upon
request from each nationwide credit bureau and from nationwide specialty consumer reporting
agencies. See www.ftc.gov/credit for additional information.
You have the right to ask for a credit score. Credit scores are numerical summaries of your
credit-worthiness based on information from credit bureaus. You may request a credit score from
consumer reporting agencies that create scores or distribute scores used in residential real property
loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score
information for free from the mortgage lender.
You have the right to dispute incomplete or inaccurate information. If you identify
information in your file that is incomplete or inaccurate, and report it to the consumer reporting
agency, the agency must investigate unless your dispute is frivolous. See www.ftc.gov/credit for an
explanation of dispute procedures.
Consumer reporting agencies must correct or delete inaccurate, incomplete, or
unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or
corrected, usually within 30 days. However, a consumer reporting agency may continue to report
information it has verified as accurate.
Consumer reporting agencies may not report outdated negative information.
In most cases, a consumer reporting agency may not report negative information that is more
than seven (7) years old, or bankruptcies that are more than ten (10) years old.
10/07
Access to your file is limited. A consumer reporting agency may provide information
about you only to people with a valid need – usually to be consider an application with a creditor,
insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for
access.
You must give consent for reports to be provided to employers. A consumer
reporting agency may not give out information about you to your employer, or a potential
employer, without your written consent given to the employer. Written consent generally is not
required in the trucking industry. For more information, go to www.ftc.gov/credit.
You may limit “prescreened” offers of credit and insurance you get based on
information in your credit report. Unsolicited “prescreened” offers for credit and insurance
must include a toll-free phone number you can call if you choose to remove your name and
address from the lists these offers are based on. You may opt-out with the nationwide credit
bureaus at 1-888-5-OPTOUT (1-888-567-8688).
You may seek damages from violators. If a consumer reporting agency, or, in
some cases, a user of consumer reports or a furnisher of information to a consumer reporting
agency violates the FCRA, you may be able to sue in state or federal court.
Identify theft victims and active duty military personnel have additional rights.
For more information, visit www.ftc.gov/credit.
States may enforce the FCRA, and many states have their own consumer reporting laws. In
some cases, you have more rights under the state law. For more information, contact your state
or local consumer protection agency or your state Attorney General. Federal enforcers are:
TYPE OF BUSINESS: CONTACT:
Consumer reporting agencies, creditors and others not listed below Federal Trade Commission
Consumer Response Center - FCRA
Washington, DC 20580 1-877-382-4357
National banks, federal branches/agencies of foreign banks Office of the Comptroller of the Currency
(word “National” or initials “N.A.” appear in or after bank’s name) Compliance Management, Mail Stop 6-6
Washington, DC 20219 800-613-6743
Federal Reserve System member banks (except national banks, and Federal Reserve Board
federal branches/agencies of foreign banks) Division of Consumer & Community Affairs
Washington, DC 20551 202-452-3693
Savings associations and federally chartered savings banks Office of Thrift Supervision
(word “Federal” or initials “F.S.B.” appear in federal institution’s name) Consumer Programs
Washington, DC 20552 800-842-6929
Federal credit unions National Credit Union Administration
(words “Federal Credit Union” appear in institution’s name) 1775 Duke Street
Alexandria, VA 22314 703-519-4600
State-chartered banks that are not members of the Federal Reserve Federal Deposit Insurance Corporation
System Consumer Response Center, 2345 Grand Avenue, Suite 100
Kansas City, Missouri 64108-2638 1-877-275-3342
Air, surface, or rail common carriers regulated by former Civil Department of Transportation
Aeronautics Board or Interstate Commerce Commission Office of Financial Management
Washington, DC 20590 202-366-1306
Activities subject to the Packers and Stockyards Act, 1921 Department of Agriculture
Office of Deputy Administrator - GIPSA
Washington, DC 20250 202-720-7051
10/07
Acknowledgement
I authorize Cogent Systems, Inc. to conduct a fingerprint based criminal history
record check of me.
I understand that Cogent Systems, Inc. will send my fingerprints to the Georgia
Crime Information Center for a search of criminal history information in its files and
to the Federal Bureau of Investigation for a search of its files when a federal
record check is so authorized.
I understand that the electronic results of this fingerprint check will be received by
Cogent Systems, Inc. and forwarded to the agency responsible for determining
my suitability for the position for which I have applied. I further understand that
Cogent Systems, Inc. will not maintain a copy of my record and that Cogent
Systems, Inc. meets all confidentiality and security requirements for handling and
dissemination of state and federal criminal history record information.
Applicant Printed Name:____________________________________________
Applicant Signature: _______________________________________________
Date: ___________________________________________________________
Registration for Fingerprints
In order to register you to have your fingerprints taken, please complete the following
information.Please print!
Last name
First Name
Middle Name
Suffix (Jr, Sr, II,III, etc.)
Date of Birth
Place of Birth (State)
Social Security Number
Gender
Eye Color
Hair Color
Height
Weight
Country of Citizenship
Drivers License Number
Driver License State
Street Address (No PO
Box)
City
State
Zip Code
Phone Number with
Area Code
GCIC CONSENT FORM
I hereby authorize the BALDWIN POLICE DEPARTMENT to receive any Georgia criminal
history record information pertaining to me, which may be in the files of any state or local
criminal justice agency in Georgia.
____________________________________________________________________________
Full Name (please print)
____________________________________________________________________________
Address
__________ __________ ____________ _______________________
Sex Race Date of Birth Social Security Number
I, _______________________________________ (Please Print) give consent to the above named to
perform periodic criminal history background checks for the duration of my employment with this
company.
________________________________________ _______________________
Signature Date
=========================================================================================
Requesting Location Address: ____________________________________________________________________
City, State, Zip: _______________________________________________________________________________
Telephone: _______________________________________________________________________________
Fax Number: _______________________________________________________________________________
Please email results to: ________________________________________________________________________
