Employee Screen Consent

EMPLOYEE SCREEN CONSENT

Personal Information

Position Information

Proposed Start Date:   Proposed Salary or Rate:

Employment History (Most Recent First)

Education

References

Screening Authorization

I, , hereby authorize the Company, its agents and contracted screening providers to obtain and evaluate information about my background for purposes of determining my suitability for employment or continued employment. This authorization applies to all screenings selected below and includes acquisition of consumer reports, investigatory consumer reports, and verification of the information I have provided.

Types of screening authorized (check all that apply):

Disclosure and Consent

I understand that the information obtained through these screenings may include, but is not limited to, criminal records, motor vehicle records, consumer credit history, education and employment records, professional credentials, and drug/alcohol testing results. I expressly authorize the release of such information to the Company and its designated screening agents. I understand that adverse results may affect hiring or continued employment decisions.

I release and discharge the Company, its agents, and any person or entity providing information from any and all liability arising from the procurement, preparation, or use of such information to the extent permitted by law. I further understand that background information obtained for employment purposes will be used in compliance with applicable local, state, and federal law.

Drug and Medical Screening

Where authorized above, I consent to submit to drug and alcohol testing and to medical examinations if required for job-related purposes. Test results and medical information will be maintained confidentially and released only to authorized personnel on a need-to-know basis, except as required by law. I acknowledge that certain positions may require a post-offer medical examination or physical capacity evaluation.

Duration, Revocation and Record Retention

This authorization remains in effect for the duration of my employment relationship and for a reasonable period thereafter to allow for legitimate retention of records, unless I provide written revocation. I understand that revocation will not affect any screening already completed. The Company will retain screening records in accordance with its records retention policy and applicable law.

Equal Opportunity and At-Will Employment

The Company is an equal opportunity employer. Screening decisions will be applied uniformly and without unlawful discrimination. Nothing in this consent or any screening process creates any contract or covenant of employment for any specified period. Employment with the Company is at-will and may be terminated by either party at any time, with or without cause, subject to applicable law.

Applicant Certification and Authorization to Contact

I certify that the information I have provided in connection with my application and in this form is true, complete, and correct to the best of my knowledge. I authorize the Company and its agents to contact previous employers, educational institutions, references, licensing authorities, and other listed sources to verify any information and to obtain any records or reports necessary for the screenings selected above.

Acknowledgment

By signing below, I acknowledge that I have read and understand this Employee Screen Consent, that I have had the opportunity to ask questions, and that I voluntarily consent to the screenings indicated. I understand that I may request a copy of this authorization.

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