Authority to Release Information

I understand that in processing my application with Professional Nursing Service an investigation may be made in which information is obtained through personal interviews, and a review of information held by law enforcement or other government agencies. I authorize you to verify my past employment and education, criminal records, credit history, motor vehicle records, personal references, and other job related data provided on this application or via the interview process. I authorize appropriate individuals, companies, institutions or agencies to release information, and I release them from any liability as a result of such inquiries or disclosures. A consumer report may be generated summarizing this information. I have a right under the "Fair Credit Reporting Act" to obtain a copy to this report by directing a written request to Verified Credentials, Incorporated.

I further understand and waive my right of privacy in this investigation and release and hold harmless Professional Nursing Service and its agent, Verified Credentials, Inc. from any liability.

I agree that any decision to hire me is contingent upon the results of my report and certify that all statements and answers on my application, resume, or interview are true and complete to the best of my knowledge. I understand that if any statements are false or that if information has been omitted, this will be cause for disqualification and immediate termination of my employment. If employed, I further authorize Professional Nursing Service to check my credit and conviction records, as needed, on a continuous basis as it relates to my employment.

Red text and boxes with yellow shading are REQUIRED fields.

First Name:        Middle Initial:
Last Name:
Previous Name/Maiden/A.K.A.s:
Date of Change:
Street Address:
City:
State:        ZIP:
Other cities and states lived in over past 7 years:
Social Security #:
Date of Birth:
Drivers License #:        State Issued:
DL Date Issued:        DL Date Expired:
  I understand that a photocopy of this authorization would be accepted with the same authority as the original. This release will expire one year after the date of origination.      Date: