PINCKNEYVILLECOMMUNITYHOSPITAL

For Employment Purposes* OR STUDENT/VOLUNTEER/JOB SHADOW/SCU RESIDENT

TO BE COMPLETED BY APPLICANT/PROSPECTIVE EMPLOYEE

PRINT LEGIBLY

NAME:

Last NameFirst Name Middle Initial

Driver’s License #:______Issued by State of ______Expiration Date:______

Current 911 Address:______
Street / Apt.# / P.O. Box

______

City StateZip Code

Applicant/Employee* Authorization

Without reservation, I authorize PinckneyvilleCommunityHospital or any party or agency contacted by this facility to procure my consumer report and/or to obtain or furnish information concerning my credit, criminal, motor vehicle, employment or other history. I understand that inquiries may be made to various federal and state agencies, employers, references, acquaintances and other seeking information as to my personal characteristics, credit worthiness, employment status, general reputation and mode of living. Under provisions of the Fair Credit Reporting Act, certain information, when used for employment purposes, is considered to be a consumer report. This information includes, but is not limited to, public record information (criminal history, civil litigation, etc.) driving records, consumer credit history, education records and employment records. If an adverse employment decision is made, due in whole or in part, to information received as a result of these inquiries, I will be provided with a copy of the consumer report and a summary of my rights under the Fair Credit Reporting Act.

Print Full Name:______

Date of Birth: ___/__ /____ Soc. Sec. #______Race/Ethnic Origin:____Marital Status____

Month/Day/Year (W)hite (B)lack (H)ispanic (A)sian/Pacific Islander (s)ingle (m)arried

(AI)merican Indian/(AN)Alaskan Native (d)ivorced (w)idowed

Applicant/Employee Signature:______

*This information is requested for the purpose of ensuring the accurate retrieval of records and for the annual completion of the Dept. Human Rights and EEO-1 reports required by the federal government. In the case of employees, this record will be kept in a separate section of the employee file and will be unavailable for review by anyone other than the H.R. Director for mandatory reporting purposes and record keeping only.

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JUVENILES

As conviction responses to juvenile arrests (individuals under 17 years of age) can only be made available if the juvenile is tried as an adult or convicted of a forcible felony, we will not run criminal background checks on youth under the age of 17 serving as Jr. Volunteers or those doing community service hours through the Perry County Youth Court. The parent/guardian/custodian of the child must sign a waiver that states the child has not been tried as an adult and has not been convicted of a forcible felony that would prohibit him/her from working in a healthcare facility.

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I hereby affirm that: ______has not been tried as an adult and has not been convicted of a forcible felony that would prohibit [ ] him / [ ] her from working in a healthcare facility.

______, ______, ______

SignatureTitle: Parent/Guardian/CustodianDate

F-HHR1130 1-14-2011