DISCLOSURE FORM & AUTHORIZATION FOR BACKGROUND CHECK
Required fields in BOLD 

I hereby authorize CAREY CONSULTANTS, INC, to conduct a background check on myself specifically for employment purposes which will be provided directly to HATZALAH OF BERGEN COUNTY. I hereby release CAREY CONSULTANTS, INC and HATZALAH OF BERGEN COUNTY of any liability and responsibility in securing and compiling this background check.

I understand this background check will consist of an identity verification report & a criminal check.

I understand and authorize that information may be obtained from any relevant criminal repositories or public records and that CAREY CONSULTANTS will be providing the report directly to myself and to HATZALAH OF BERGEN COUNTY. I understand that Carey Consultants, Inc., will bill me directly and that no information will be processed until payment is received via PAY PAL or via a check through regular mail.

The following fees will apply - Please "Check" where applicable:
NJ STATEWIDE CRIMINAL CHECK, $45.00
If you have resided in multiple locations within the past 10 years, we will have to conduct a criminal check in those jurisdictions, the following fees will apply
ANY OTHER STATES (except NY, MA or Fl), the fee will be $45.00 EACH / LIST STATES Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Guam Northern Mariana Islands Puerto Rico United States Minor Outlying Islands Virgin Islands Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Northwest Territories Nunavut Yukon
Massachusetts, the fee is $75.00
New York State, the fee is $101.50
Florida, the fee is $75.00

Upon completion of this form you will be redirected to a payment page. (Multiple location fee will be billed to your email address separately)

Please also indicate that you have read YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT Please make a selection.

I UNDERSTAND FURTHER THAT ALTHOUGH THIS IS A BACKGROUND CHECKING FORM AND NOT AN EMPLOYMENT APPLICATION,
FALSIFYING ANY INFORMATION ON THIS FORM MAY LEAD TO MY IMMEDIATE DISMISSAL OR DISCONTINUATION OF MY CANDIDACY
FOR ANY POSITION, CONTRACTING ASSIGNMENT, PROMOTION OR TRANSFER.

By signing this form, you agree to all of the stipulations outlined above:

Digial Signature*	A value is required.
Email Address*	A value is required.
Social Security Number *	A value is required.
Date of Birth ( DD/MM/YYY) *	A value is required.
Place of birth*	A value is required.
DOT ID NUMBER (if applicable)
List any former names used & years utilized:
Personal Driver’s License Number*	A value is required.
State issued *	A value is required.
Commercial Driver’s License Number
State issued
Current Street Address *	A value is required.
City *	A value is required.
State, Province *	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Guam Northern Mariana Islands Puerto Rico United States Minor Outlying Islands Virgin Islands Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Northwest Territories Nunavut Yukon Please select an item.
Postal code *	A value is required.
How long have you resided at the above address? *	A value is required.
List all previous addresses within the past 10 years:
Have you ever been convicted of a crime other than a minor traffic violation?* Yes No Please make a selection. If yes, please indicates years, circumstances & place of occurrence
Has your driver’s license ever been suspended or revoked* Yes No Please make a selection. If yes, please explain where/when/why
Have you been terminated from any place of employment within the past 7 years? * Yes No Please make a selection. If yes, please indicate name of employer, cause for discharge & month/year this termination took place:
If you do not presently have a driver’s license, please explain why not?
Have you ever received a dishonorable discharge from the Armed Services? Yes No If yes, Please explain

CAREY CONSULTANTS
P.O. BOX 176
CHARDON, OH 44024

www.careyconsultants.com
NJ STATE POLICE LICENSE: 4326
800 359 2804 F 440-354-6134