Prime Home Care does not discriminate in hiring or employment on the basis of race, color, religious creed, national origin, sex, marital status, sexual orientation, gender identity or expression, ancestry, disability with or without reasonable accommodation, status as a disabled veteran or Vietnam Era veteran or on the basis of age. You will be required to produce documentation/identification that will determine your legal right to be employed in the United States.
EDUCATION, LICENSES, AND CERTIFICATIONS
WHAT POSITION ARE YOU APPLYING FOR?
TELL US ABOUT YOUR WORK EXPERIENCE
Disclosure Regarding Background Investigations
Under a federal law called the Fair Credit Reporting Act, we are required to disclose information to you concerning our conducting background checks.
Prime Home Care (the "Company") may obtain information about you from a consumer reporting agency for the purpose of either hiring you or if you have been hired, retaining you in employment. This means you may be the subject of a "consumer report" (a background report) or "investigative consumer report" which may include information concerning your character, mode of living, general reputation, personal and/or work characteristics, and credit standing, The types of information that may be ordered include but are not limited to: Social Security number verification; criminal records information, education information and, as appropriate, driving records checks; verification of prior employment; reference, licensing and certification checks; credit reports; drug testing results; and, worker's compensation history. Credit history will only be requested where such information is substantially related to the duties and responsibilities of the position for which you arc applying. Our organization uses the firm of Research Services 4 Brothers LLC (the "Consumer Reporting Agency") to obtain and report this information to us. The Consumer Reporting Agency may be reached at 124 Simsbury Rd, Avon, CT 06001, by e-mail contact@rs4b.net, and by telephone 860-678-0066. You have the right upon your written request made in a reasonable period of time after receipt of this notice, to ask if a consumer report has been made about you and the nature and scope of any investigative consumer report and to request a copy of the report.
The background check will only be conducted with your written authorization using a separate document.
Authorization to Conduct Background Investigations
I acknowledge that I have received a Disclosure Regarding Background Investigations which informed me that as part of the decision to hire me or retain me in employment if hired, I may be the subject of a "consumer report" (a background report) or investigative consumer report" which may include information concerning my character, mode of living, character, general reputation, personal and work characteristics, and credit standing. The types of information that may be ordered include but are not limited to: Social Security number verification; criminal, educational and, as appropriate, driving records checks; verification of prior employment; reference, licensing and certification checks; credit reports; drug testing results; and, if applicable, worker's compensation injuries. This information may involve personal interviews with sources such as my neighbors, friends and associates. Credit history will only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying. This information may be obtained my past or present employers; learning institutions, including colleges and universities; any law enforcement agency; federal, state and local courts; the military; credit bureaus; testing facilities; insurance companies, motor vehicle, records agencies; worker's compensation commissions and agencies all other public sector repositories of information;
The organization to which I am applying uses the firm of Research Services 4 Brothers LLC (the "Consumer Reporting Agency") to obtain and report this information.
Authorization
I hereby authorize the obtaining of information as described above needed for the development of "consumer reports" and/or "investigative consumer reports" about me at any time after the receipt of this authorization, and if I am hired, throughout my employment. To this end, I also authorize the following agencies and entities to disclose to the Consumer Reporting Agency and its agents all information about or concerning me, including but not limited to: my past or present employers; learning institutions, including colleges and universities; any law enforcement agency; federal, state and local courts; the military; credit bureaus; testing facilities; insurance companies, motor vehicle records agencies; worker's compensation commissions and agencies all other public sector repositories of information; Such information that can be disclosed to the Consumer Reporting Agency and its agents.
PRIME HOME CARE
Background Check Information
The information requested below is collected solely for the purpose of aiding the Company you have applied to in connection with your application for employment. Please provide the information below to assist in conducting a thorough background check
Address Used Within the last 7 years
use separate sheet if needed
For Employer Use Only
fax to:(860) 678-1996 / (860) 678 0099
Email: contact@rs4b.net
STATE DISCLOSURES
This page is for your records
CALIFORNIA:
ou may view the file that the Consumer Reporting Agency has for you, and order a copy of the file, upon submitting proper identification and paying copying costs, by coming to their offices, during normal business house and reasonable notice, or by certified mail or mail. You may also ask fora file-summary by telephone. The Consumer Reporting Agency answer questions about the information in your file, including any coded information. If you come in person, another person can come with you, so long as that person can show proper identification.
MAINE
If you ask us, you have the right to know whether the Company ordered an investigative consumer report on you. You may request the name, address, and telephone number of the nearest office for the Consumer Reporting Agency. You will get this information within 5 business days of our receipt of your request. You have the right to ask the Consumer Reporting Agency for a free copy of the report.
MARYLAND:
If the Company obtains credit history information on you, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.
MASSACHUSETTS/NEW JERSEY:
If you submit a request to us in writing, you have the right to know whether the Company ordered an investigative consumer report from the Consumer Reporting Agency. You may inspect and order free copy of the report by contacting the Consumer Reporting Agency.
MINNESOTAIf you submit a request to us in writing, you have the right to get from the Company a complete and accurate disclosure of the nature and scope of the consumer report or investigative consumer report ordered, if any.
NEW YORK If you submit a request to us in writing, you have the right to know whether the Company ordered a consumer report or an investigative consumer report from the Consumer Reporting Agency, and you will be provided with the name and address of the Consumer Reporting Agency. You may inspect and order a free copy of the reports by contacting the Consumer Reporting Agency. By signing below, you certify you have received a copy of Article 23A of the New York Correction Law is being provided with this form.
OREGONIf the Company obtains credit history information on you, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.
WASHINGTON STATE:If you submit a request to us in writing, you have the right to get from the Company a complete and accurate disclosure of the nature and scope of the investigative consumer report we ordered, if any. You also have the right to ask the Consumer Reporting Agency for a written summary of your rights under the Washington Fair Credit Reporting Act. If the Company obtains information bearing on your creditworthiness, credit standing or credit capacity, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.
This page is for your records
