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Hospital: 701-965-6384
Crosby Clinic: 701-965-6349
Care Center: 701-965-6086

Applicant Disclosure and Authorization Form






    [Important– Please read cairfully before signing Authorization]

    Disclosure regarding background investigation

    St. Luck’s Hospital, Clinic, and/or Sunrise Care Center (“The Company”) may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character. general reputation, personal characteristics, and/or mode of living, which can involve personal interviews with sources such as your neighbors, friends, or associates. These report may contain information regarding your credit history, social security varification, motor vehicle records (“driving record”), verification of your education or employment history including current position, worker’s compensation injuries, or other background checks. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by [One Source The Background Check Company, PO Box 24148 Omaha, NE 68124, 1.800.608.3645] or another outside origanization. The scope of this notice and authorization is all-encompassing, however, allowing St. Luck’s Hospital, Clinic, and/or Sunrise Care Center to obtain from any outside origanization all manners of consumer reports and invstigative consumer report now and throughout the course of you employment to the extent permitted by law. As a result, you should cairfully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

    Acknowleggment and Authorization

    I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I here by authorize the obtaining of “Consumer reports” and/or “investigative cosumer report” by the company at any time after receipt of this authorization and throughtout my employment, Id applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or univesity (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by [One Source the Background Check Company, PO Bpx 24148 Omaha, NE 68124, 1.800.608.3645]. another outside organization acting on behalf of St. Luke’s Hospital, Clinic, and/or Sunrise Care Center itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

    • New York applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by St. Luck’s Hospital, Clinic, nad/or Sunrise Care Center by contacting the consumer reporting agency identified above directly.
    • Minnesota and Oklahome applicants or employees only: Please check this box if you would like to receve a copy of a cinsumer report if one is obtained by the company.
    • Califonia applicants or employees only: By siging below, youalso acknowledge receipt of the Notice Regarding Background investigation pursuant to California LAW. Plaese check this box if you would like to receive a copy of an investigatice consumer report or consumer credit report at on charge if one is obtained by the company whenever you have a right to receive a copy under California law.
    Last Name
    First
    Middle
    Other Names/Alias
    Social Security*#
    Date Of Birth*
    Driver’s License#
    State of Driver’s License
    Persent Address
    Phone Number
    City
    State
    Zip
    All Previous Addresses in The Last Seven Years
    Agency/Organization Of License
    State Issue
    License#
    Signature
    Date

    *The information will be used for background screening purposes only and will not be used as hiring criteria.

    INFORMATION FOR GOVERNMENT MONITTORING PURPOSES

    The following information is requested by the Federal Government is order to monitor compliance with appliable Federal Civil Right laws. You are not required to furnish this information, but are encouraged to do so. The law states that a provider of services may neither discriminate on the basis of this information, not on whether you choose to furnish it. However, if you choose not to furnish it, under Federal regulations the provider of services is required to note race, ethnicity, and sex on the basis of vidual observation or surname.

    Ethnicity (mark one)
    Not Hispanic or LitionHispanic or Lation
    Race (mark one or more)
    WhiteBlack or African AmericanAmerican Indian/Alaska NativeAsianNative Hawaiian or Other Pacific Islander2 or more racesOther
    Sex

    Policy Title

    Committees

    First Effective Date

    Revision/Review Date

    Date

    Consent and Release for Drug Testing (Pre-Employment)

    I understand that pursuant to St. Luke’s Hospital’s Policy for a drug and Alcohol-Free Workplace,
    I am being required to drug screening test.

    I hereby consent to submit to urinalysis, saliva, breath, blood, and/or other tests as shall be determined by St. Luke’s Hospital for the purpose of determining the use of illegal drugs and/or alcohol.

    I agree that St. Luke’sHospital, or an alternate company selected facility, may collect these speciment for these teste and may test them or forward them to a testing laboratory designated by St. Luke’s Hospital.

    I understand that is the current illegal use of drugs and/or abuse of alcohol that prohibits me form obtaining employment with St. Luke’s Hospital, nad it’s affiliates.

    I am unaware of any medical condition that would indicate that either the screen or physical examination might endanger my physical health.

    I agree to hold harmless St, Luck’s Hospital and it’s agents from any liability arising in whole or part out of the collection of specimens, testing, and use of the information form said testing in connection with St. Luck’s consideration of any employment.

    I agree that a reproduced copy of this consent and release form shall have the same force and effect as the original.

    I have carefully read the foregoing and fully understand it’s contents. I acknowledge that my signing of this consent and release form is a voluntary act on my part and that I have not been coerced into signing this document by anyone.

    Applicant Nmae (Printed)

    Appliant Signature

    Social Security Number or UID

    Parent/Guardian Name, if under 18 yrs (Printed)

    Parent/Guardian Signature