I certify that the information given on this application and in any other supporting documentation, resume, etc. is true and correct. I understand that any false information, willful or negligent misrepresentation, or failure to disclose any requested information will constitute sufficient grounds for Hope Hospice, Inc. to terminate my employment without notice. I further understand that Hope Hospice, Inc., will perform a pre-employment investigation to determine my suitability for employment and I authorize Hope Hospice, Inc., to secure the information necessary to make a decision. I hereby release from liability any and all individuals and organizations who provide information to Hope Hospice, Inc., concerning my professional competence, ethics, character and other qualifications and authorize my prior employers to release any requested information from my personnel files. I further understand that Hope Hospice, Inc., will adhere to applicable state and federal statues concerning the securing of information, handling, utilization and release of information obtained in the pre-employment investigation. I acknowledge by my signature that I have read and understand these statements

Hope Hospice 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 Hope Hospice 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.

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 Hope Hospice I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

The following is for identification purposes only to perform the background check and will not be used for any other purpose: