Bethany Retirement Living is an Equal Opportunity Employer
201 University Dr. S., Fargo, ND 58103 (701) 239-3000
APPLICANT DISCLOSURE AND RELEASE FOR BACKGROUND CHECKS, DRUG SCREENING, AND REFERENCE INFORMATION
Having made application for employment with Bethany Retirement Living, and desiring them to be informed as to my previous record and character, I hereby authorize Bethany Retirement Living and its authorized representatives to obtain information relating to my activities from educational institutions, licensing agencies and all persons or entities named on my employment application. This information may include, but is not limited to, academic, achievement, performance, attendance, personal history, discipline and conviction records. I hereby direct you to release such information upon the request of the bearer.
Further, I release any and all individuals and organizations, including record custodians, from and and all liability for damages of whatever kind or nature because of furnishing said information.
In connection with my application for employment with Bethany Retirement Living, I also understand that background checks will be performed on me if I receive an offer of employment from Bethany Retirement Living. I understand that an offer of employment is conditional on the results of the background information. The background information will be obtained through:
ADVANTAGE CREDIT BUREAU
5050 47th St S, Fargo, ND 58104
Toll free phone: 1-800-568-4478 / Fax: 701-239-9963
I understand the information obtained from a background check my include my past employment history, criminal history and driving record. I further understand that the background information is not limited to the current state of my residence, but may include information from any other state where I have resided.
I authorize all persons and companies contacted by the employer or its representatives to provide the requested background information. I understand and agree to release the aforesaid from any liability for collecting my background information.
I understand that if adverse action is taken by Bethany Retirement Living based on the results of my criminal background check, I will be given notice orally, in writing, or electronically of such adverse action. I further understand that I may request in writing within a reasonable period of time, a complete disclosure of the nature and scope of the background investigation. I also understand that I have the right to dispute the accuracy or completeness of any information furnished by the reporting agency. I further understand that the reporting agency supplying the information does not make the decision to take adverse action and cannot give specific reasons for the adverse action, only the employer makes such a decision.
I further authorize Bethany Retirement Living, if I am hired, to request a background report about me, for employment related purposes, at any time during the course of my employment to the extent allowed by law. I agree that this Disclosure and Release will be valid, now or in the future, in original, faxed, copied, or electronic form.
I also give my consent to Bethany Retirement Living and to Sanford Laboratory to perform the appropriate test(s) to identify the presence of drugs and/or alcohol. I furthermore give my permission for the test results to be released to Bethany Retirement Living. I understand that refusal to take this test, attempts to adulterate the sample, or a positive test may result in Bethany Retirement Living removing my application from consideration. In addition, I understand that Bethany Retirement Living does not allow smoking on its property. Name *