Harbert Hills Nursing Home - Background CheckEMP - Background Check Employment Consumer Report Release and AuthorizationThe purpose of this form is to notify you that a Consumer Report will be conducted on you in the course of consideration for employment, promotion, or Tenant Screening. This report is being provided by CIC Mortgage Credit, Inc.- 327 Caldwell Dr #100 Goodlettsville, TN 37072 — Phone 800-352-5882. | hereby authorize your company or any agent of your company to contact any and all corporations, former employers, credit agencies, educational but not limited to, information about my employment, education, consumer credit history, driving record, criminal record, and general public records but not limited to, information about my employment, education, consumer credit history, driving record, criminal record, and general public records collecting the above information. This release shall remain in effect for •the length of my employment or Rental agreement. I understand I have the right to obtain a free copy of this Consumer Report if; (l) Any adverse action/decision is made based on the information in the consumer report, & (2) If the request is made in writing within 60 days of the adverse action. I believe to the best of my knowledge that all information I have provided is accurate true and correct and that I fully understand the terms of this release.Please write clearly First Name * Middle Last Name * List any maiden/other name used ni the last 7 years. Date of birth * Social Security Number * Drivers License # * State * Sex * Male Female Email * Phone * Street * City * State * Zip * I authorize CIC Credit to obtain and verify information relating to my background, and create a report of its findings. Information may include, but is not limited to: criminal records, motor vehicle records and any data that is provided on my application or resume or information obtained during the interview process. I understand that CIC Credit will provide the information as it is reported in the applicable public records at the time of CIC Credit's request or at the time CIC Credit obtains the information from other credit reporting agencies, and therefore CIC Credit cannot and does not guaranty the accuracy of the information reported. Accordingly, I release and hold harmless CIC Credit and its agents from any liability related to the accuracy of that information, to the extent that CIC Credit accurately transcribed the information provided to it.I further understand and waive my right of privacy in this matter, I authorize the appropriate individuals, companies, institutions or agencies to release information to CIC Credit, and I release those entities, to the extent allowable by law, from any liability as a result of such inquiries or disclosures.I have read and understand this disclosure and consent form. By checking the box at the end of this statement I am authorizing CIC Credit to conduct a consumer report and certify that I am responsible for payment for all services requested.I Agree Yes Signature signature keyboard Clear Date Submit If you are human, leave this field blank.
