Background Consent

AGREEMENT, AUTHORIZATION AND CONSENT FOR RELEASE OF BACKGROUND INFORMATION:

I,
Name
understand that in conjunction with my application for employment, work to be performed under contract, promotion, volunteer position, reassignment, and/or retention ("Work"), Cotton, LLC Woodside Healthcare Center will use the services of an outside agency to research and verify the information I have provided on my application for employment, including my personal background, character, professional work history and qualifications, This agency will provide a written report of its findings to Cotton, LLC Woodside Healthcare Center. Cotton, LLC Woodside Healthcare Center uses ENZIO, a consumerreporting agency, as an agent to perform its Employment related background investigations. ENZIO will various sources of information, It deems appropriate including but not limited to: criminal conviction records, current and former employers, department of motor vehicle records, military records, credit reporting agencies, education records, professional and personal references and compensation records including any and all injuries in compliance with the Americans with Disabilities Act. agree, authorize and consent to the release and disclosure of any and all information including but not limited to the above to Cotton, LLC Woodside Healthcare Center, and ENZIO. I agree, authorize and consent to the procurement of a Consumer Report and/or an Investigative Consumer Report and understand that it may contain information about my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living, this authorization in original or copy form shall be valid for my term of Work from the date indicated next to my signature. According to the Fair Credit Reporting Act, I be notified Cotton, LLC Woodside Healthcare Center if Work is denied because of information obtained from a Consumer Reporting Agency, Additionally, I understand that if requested within 60 days, I will be given a full and accurate disclosure as to the nature and substance of all information provided to Cotton, LLC Woodside Healthcare Center I further understand that I may request a copy of the report, and that when doing so, proper identification will be required, and I should direct my request to: ENZIO. I understand that residents all states will automatically receive a copy of the report if an adverse action is taken regarding the employment application, or upon request as outlined herein,
CHECK THIS BOX: IF are applying for work with a California, Minnesota or Oklahoma based employer and you would like a copy of your Consumer Report if one is prepared in the investigation of your background. CA Codes 1785.20.5 & 1785 & 1786.18(a)(5)(b)(1), MN Code 13C Subdivision 2, OK Code 24 0.S, 148

LAW ENFORCEMENT AGENCIES AND OTHER ENTITIES FOR POSITIVE IDENTIFICATION PURPOSES REQUIRE THE FOLLOWING INFORMATION WHEN CHECKING PUBLIC RECORDS, IT IS CONFIDENTIAL AND WILL NOT EIE USED FOR ANY OTHER PURPOSES, PLEASE PRINT CLEARLY.

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Corporate Office: Cypress HealthCare Group 2266 Lava Ridge Ct. #105 Roseville, CA 95661 (V1 051322)

Contact Us

Woodside Healthcare Center
2240 Northrop Avenue
Sacramento, CA 95825
(P) 916-927-9300
(F) 916-927-9654
(E) aportela@cypressh.com