Background Check Authorization Form
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2 Background Check Authorization Form
Consent for Criminal Background History Check
Authorization/Waiver/Indemnity
Each employee or volunteer to be screened must sign an authorization/waiver/indemnity form, giving
approval for Ruth Eckerd Hall, Inc. to perform a criminal background check.
I hereby give my permission to Ruth Eckerd Hall, Inc. to obtain information relating to my criminal
history record. The criminal history record, as received from the reporting agencies, may include arrest
and conviction data as well as plea bargains and deferred adjudications and delinquent conduct
committed as a juvenile. I understand that this information will be used, in part, to determine my
eligibility for an employment/volunteer position with this organization. I also understand that as long as
I remain an employee or volunteer here, the criminal history records check may be repeated at any
time. I understand that I will have an opportunity to review the criminal history as received by Ruth
Eckerd Hall, Inc. and a procedure is available for clarification if I dispute the record as received. I also
understand that the criminal history could contain information presumed to be expunged.
I hereby affirm that my answers to the foregoing questions are true and correct and that I have not
knowingly withheld any fact or circumstances that would, if disclosed, affect my application unfavorably.
I understand that any false information submitted in this application may result in my discharge.
I, the undersigned, do, for myself, my heirs, executors and administrators, hereby remise, release and
forever discharge and agree to indemnify the Ruth Eckerd Hall, Inc. and each of their officers, directors,
employees and agents and hold them harmless from and against any and all causes of actions, suits,
liabilities, costs, debts and sums of money, claims and demands whatsoever (including claims for
negligence, gross negligence, and/or strict liability of the Ruth Eckerd Hall, Inc.) and any and all related
attorneys’ fees, court costs and other expenses resulting from the investigation of my background in
connection with my application to become a volunteer/staff member.
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_________________________
Applicant’s Signature
Date
___________________________________
__________________________
Parent or Guardian Signature (if applicant is under 18 years) Date
___________________________________
______________________________________
Applicant’s Printed Name (last, first) List maiden name or any other name used
Gender: Male Female
Date of Birth (month/day/year): ____________
Address History (past 5 years required)
Social Security Number: ___________________
Current Address: _________________________
________________
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________
Street
City
State # Yrs at Address
Previous Address: ________________________
________________
____
_________
Street
City
State # Yrs at Address
Previous Address: ________________________
________________
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_________
Street
City
State # Yrs at Address
Previous Address: ________________________
________________
____
_________
Street
City
State # Yrs at Address
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Parent category: Legal