Applicant's Full Name*
Date of Birth*
Provide if you prefer to receive information via email
Address*
Address on Driver's License*
Name on GED or under which you graduated
Do you have any current professional licenses, certifications, or registries?*
Do you have another State/Region or Issuing Organization?*
Have you ever been convicted of, plead guilty, no contest, or nolo contendere to a misdemeanor or felony?*
Do you have another offense?*

Please provide all locations where you have resided for the past seven (7) years, starting with your current residency.

Address 1 *
Date From*
Date To *
Address (2)
Date From (2)
Date To (2)
Address (3)
Date From (3)
Date To (3)
Address (4)
Date From (4)
Date To (4)
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DISCLOSURE REGARDING BACKGROUND INVESTIGATION
Adventist Health System Sunbelt Healthcare Corporation and/or its subsidiaries, parents, successors, and affiliates (the d"Company") may order a consumer report on you from a consumer reporting agency ("CRA") in connection with your application
for employment and, if you are hired, may order additional consumer reports on you from such an agency for employment purposes.


The consumer reports may contain information concerning your character, general reputation, personal characteristics, credit standing, and mode of living. To the extent allowed by law, the reports may contain information regarding: public records; driving records; verification of your prior employment, licenses, credentials, and education; credit reports; government watch
lists; address history; Social Security number validation; and other background checks.

ACKNOWLEDGMENT AND AUTHORIZATION

By signing below, I authorize Adventist Health System Sunbelt Healthcare Corporation and/or its subsidiaries, parents, successors, and affiliates (the "Company") to order consumer reports and investigative consumer reports from any consumer reporting agency ("CRA"), to the extent allowed by law, including the current CRA, PreCheck, Inc. I understand that, to the extent allowed by law, AdventHealth may rely on this authorization to order additional consumer reports and investigative consumer reports from any CRA without asking me for my authorization again during any period of employment.

For the specific purpose of preparing consumer reports and investigative consumer reports for AdventHealth, and subject to all laws protecting my privacy, I authorize the following to disclose to the CRA the information needed to compile the reports: law enforcement and all other federal, state, and local agencies; all courts; my past or present employers; learning institutions; including colleges and universities; credit bureaus; and motor vehicle records agencies.

My present employer may be contacted for a job reference*
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