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Background Check


CHEYENNE COUNTY HOSPITAL CONSENT FOR PRE-EMPLOYMENT REFERENCE AND BACKGROUND CHECKS

I recognize that any offer of employment to me by Cheyenne County Hospital ("HOSPITAL") is conditional upon my successfully passing reference and background screenings. I understand that HOSPITAL shall conduct pre-employment reference and background checks thoroughly and within the confines of all applicable state and federal laws. In consideration of HOSPITAL's review of my application for employment, I hereby release any individual, entity, and HOSPITAL from all claims or liabilities that might arise from the inquiry into or disclosure of such information, including claims under any federal, state, or local civil rights law and any claims for defamation or invasion of privacy.

I hereby voluntarily consent to and authorize HOSPITAL, or is authorized representative bearing this release or copy thereof, in connection with my application for employment with HOSPITAL, to conduct the following reference and background checks for employment purposes including:

 Criminal History
 Department of Motor Vehicle History
 Certification and Licensing
 Educational Credentials
 OIG List of Excluded Individuals/Entities
 Employment Eligibility (Social Security Number Check)
 Employment Checks
 Reference Checks
 Consumer Reports

I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any investigative consumer report of which I am the subject, if such request is made within a reasonable time after the date thereof. I also understand that I may receive a written summary of my rights under 15 U.S.C. 1681 § et. seq.

I authorize all persons who may have information relevant to this research to disclose such information to HOSPITAL, or its agents, and I hereby release all persons from liability on account of true and accurate disclosure. I hereby further authorize that a photocopy of this authorization be considered as valid as the original. Should there be any questions as to the validility of this release, you may contact me as indicated.

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