Craft Health Background Release Form

Name (please enter full name) *

First

Middle

Last

List any former names used

Social Security Number *

Date of Birth *

Phone Number *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

List any addresses for the past seven (7) years (street address, city, state, zip code) *

Driver's License Number (Enter N/A if driving is not part of the job) *

State Issued (Enter N/A if driving is not part of the job) *

Pursuant to the federal Fair Credit Reporting Act (FCRA), I hereby authorize Craft Health and its designated agents and representatives to conduct a comprehensive review of my background through a consumer report and/or an investigative consumer report to be generated for employment, promotion, reassignment or retention as an employee. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas: verification of Social Security number; current and previous residences; employment history, including all personnel files; education; references; credit history and reports; criminal history, including records from any criminal justice agency in any or all federal, state or county jurisdictions; birth records; motor vehicle records, including traffic citations and registration; substance abuse testing; and any other public records. I authorize the complete release of these records or data pertaining to me that an individual, company, firm, corporation or public agency may have. I hereby authorize and request any present or former employer, school, police department, financial institution or other persons having personal knowledge of me to furnish Craft Health or its designated agents with any and all information in their possession regarding me in connection with an application of employment. I understand that, pursuant to the federal Fair Credit Reporting Act, if any adverse action is to be taken based upon the consumer report, a copy of the report and a summary of the consumer's rights will be provided to me. This Authorization is valid for obtaining “consumer reports” and/or “investigative consumer reports” by Craft Health at any time after receipt of this authorization and throughout candidate’s employment, if applicable. I understand that by typing my name below and clicking on "Submit", I am electronically signing this document and am certifying that the above information is true and correct *

Date *