DISCLOSURE
FORM & AUTHORIZATION FOR BACKGROUND CHECK
Required
fields*
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
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 fees will be available on checkout)
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
*
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?* Please make a selection. If yes, please
indicates years, circumstances & place of
occurrence
Has your driver’s license ever been suspended or revoked*
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?
* 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?
If yes, Please
explain
(May take a few moments to be redirected to Payment page)
ALL INFORMATION WILL BE
HELD IN STRICT CONFIDENCE.