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Highest grade completed
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Do you have specific work experiences, job related skills or qualifications acquired from employment, internships and/or specialized training, directly related to the healthcare industry? If so, please explain.
Please Initial for consent
Please initial for consent
By submitting this form and typing your name, you are confirming information on this application is correct and information is accurate
Pre-Employment Inquiries Release and Consent Form
In connection with my application for employment, or contract to provide services on behalf of this agency, I understand and consent that investigative background inquiries will be made on me to include criminal, driving, experience, education and general character. I further understand that this agency will be requesting this information from previous employers, various federal, state, or other agencies which maintain records concerning my past activities relating to my driving record and any criminal convictions.
In accordance with NC GS 114-19.10, if I have not been a resident of the State of NC for the past five (5) years as of the date of the application, it is understood that the investigation will include my fingerprinting to be submitted for a national criminal history record check. I also understand that any offer of employment made will be contingent upon verifying the non-existence of a criminal record that would disqualify me from employment in the position for which I have applied.
I authorize, without reservation, any party or agency contacted by ComServ, Inc. to investigate my past record and to access any and all information which may concern my record and character, whether same is of record or not.
The Following Information Will Be Used To Run the Criminal Background Check