P ier! TeneT BACKGROUND & CREDIT CHECK DISCLOSURE AND AUTHORIZATION FORM DiscLosuRE This form, which you should read carefully, has been provided to you because a Tenot Healthcare facity (the *Company”) may request consumer reports on you from a consumer Feporting agency. The Company wil use ary such roports) solely for ‘employment purposes, including those associated with contactors, students, volurtser, physllane and olner performing work for the Company. Coneumer reports on you wl be obtained by the Company from HireRigh, Inc, CHieRight) located at 2100 Main Street, Sue 400, vine, CA $2614. They can be contacted at 1 800-400-2761. Information that may be obiained includes socal securly number veriestion, ciminal record, public court records, educaional records, veifcaion of employment postions eld and vetfeaion of ensing and corteations. Tha information contained In those reports may be obtained by HirRight rom private _ndior public record seurcas ining sources Ientfied by you in your job application ‘© A-crot history wal be procured only i tho postion you are applying for has fuclary or cash handling responsibity You would be issued a corporate creditcard ence employed, ori you wil be entering info @reloeaton agroenreni- A ddrving records check willbe procured onl he pasion you are appying for requites a vai eve’ cense. \Wih his Disclosure and Authorization farm you are also being provided copy of “Summary of Your Rights Under the Fair Crodit Reporting Act" issued by the Federal Trade Commission. AUTHORIZATION By signing your rare below you *+ Indicate you have carefully read and understand this Disclosure and Authorization form *Consentto the release of consumer reports tothe Company in conjunction vith your jab aplication + Understand that the Company hires you, your consent wil apply thzeughovt your employment Unies you revoke or cancel your consent in wring by sending a signed ltr or statoment to tre company ‘+ Authorize the Gisclosure fo HirsRigt of information concerning your employment history, eaming history, education, criminal history, credit hatory (when pertinent fo the positon being applied for) and motor vehicle history (when pertinent to the positon boing apie for). ‘This Disclosure and Authorization form, in original, faxod, photocopied or electronic form, wil be vad for any reperts that may be requested by the Company. Signature: __ : Date: Pint or Type: Last Nome: ist nan Mido: ‘Sola Securty oe Date of Bit (fo 1D purposes ony) Present Aira: Cyistateze ies and residerts of Califomi, Minnesota and Oklahoma: Pleasa check the appropriate box blow. 1 would tke a copy ofthe report D7 waive my right o ceive a copy of the report Hyou tive or are applying fr a jb in the state of Calfomia, please review tis adetional notice: You may view the fle maintained fn you by HireRight cing normal business hours. You may aio obtain a copy ofthis fle, upon eubmiting proper isenifcalion ad paying the costs of duptcation services, by appearing at HirsRight's offees in person, during nomal business hours and on reasonable notice, or by mal. You may also recave a summary of the fle by teleshone. HreRigh has trained pereonne! avaliable {explain your fle to you, Including any coded informatn” I you appear in person, you may be accompanied by one other person, provided that person fumishes proper identfeation“~ TeneT, CONTRACT WORKER/VOLUNTEER BACKGROUND INFORMATION SHEET For All Positi Position Desired: Facility Name: Personal Data: Name as it appears on Social Security card: is Other Names Used: Social Security Number: Date of Birth: ecistepeee ae Driver's License Number: State Issued: ___ Expiration Date: Educat ‘School Attended: oe City/State: Degree Earned: Date Earned: License Type: License Number: State Issued: ae