Application for Employment Agreement


I certify that the information provided in this application is true and complete to the best of my knowledge and I understand that one or more falsified statements within this application are grounds for dismissal.

  I hereby authorize INDISPENSABLE HEALTHCARE, its staff, and/or its agents (The Reference Company) to request information from, and consult with former employers, educational institutions (including transcripts), law enforcement agencies, credit agencies and the individuals with whom I have been associated, and with others who may have information regarding my competence, character and qualifications, and any and all sources deemed appropriate by INDISPENSABLE HEALTHCARE, or to their agents.

  I understand that such reports may contain public records information concerning my educational achievements, professional licenses, credit reports, licenses, registrations and certifications, motor vehicle reports, criminal records, etc., from federal, state and other agencies which maintain such records.  These reports may include the following types of information: names of previous employers, dates of employment, and reasons for termination of employment, work experience, job performance, accidents, etc.

  In the event that the information from the report is utilized in whole or part in making an adverse decision with regard to your potential employment, we will provide you with a copy of the consumer report and a description in writing of your rights under the law.  Under federal law, you may request in writing additional information regarding the nature and scope of this investigation. I hereby release INDISPENSABLE HEALTHCARE, its staff, its clients, and its agents from any and all liability for their acts performed in the investigation, consideration, and evaluation of my credentials and qualifications.

  I further release from any liability all former and present employers, and all individuals and organizations that provide information concerning my competence, character, other qualifications, and other applicable background information for my employment consideration.

  I authorize that a photocopy or fax transmittal of this release be accepted with the same authority as the original.  I specifically waive written notice of any information provided by any present or previous employer.

I Agree   |    I do NOT Agree