Please list 4 professional references (not relatives). Give name and current phone number and relationship to you.
[Example: teacher, co-worker, landlord, doctor, pastor, rabbi, manager/supervisor, business owner, roommate, etc.]
List previous jobs starting with most recent. If you need more room attach another sheet or write on back. It is important to list duties
and/or experiences related to home care, nursing or any specific therapy you are qualified for.
Disclosure and Authorization for Background Investigation
I hereby authorize Home Care Solutions (hereinafter referred to as The Company), Global HR and the
Minnesota Department of Human Services, as directed by The Company, to obtain a consumer report
and / or an investigative consumer report for employment purposes. I understand this report may
include inquiries regarding my educational background; work history; court records; including criminal
as permitted by law; driving history; workers compensation history; immigration status; general
reputation; performance; experience; and references obtained from professional and personal associates
and other qualities pertinent to my qualifications, for employment, including reasons for termination of
past employment. I further understand and agree that a consumer report may be obtained at any time,
and any number of times, as The Company in its sole discretion determines is necessary before, during,
or after my employment.
Medical and worker s compensation information will only be requested in compliance with the Federal Americans
with Disabilities Act (ADA), and / or any other applicable state laws. The Fair Credit Reporting Act gives you specific
rights. If we rely on the report for an adverse action, before taking the adverse action we will give you a pre-adverse
action disclosure that includes a copy of the report.
By my signature below, I hereby authorize all previous employers, educational institutions, consumer reporting
agencies, and other persons or entities having information about me to provide such information to The Company or
other entity, including Global HR and the Minnesota Department of Human Services, that obtains information for the
company. I further fully release The Company, its employees, officers, directors, agents, successors and assigns, and
all other parties involved in this background investigation, including but not limited to Global HR and the Minnesota
Department of Human Services, and its employees, officers, directors and agents, and including all consumer reporting
agencies, and those companies or individuals who provide information to Global HR, the Minnesota Department of
Human Services or The Company concerning me, from any claims or actions for any liability whatsoever related to the
process or results of the background investigation.
My signature allows a photocopy or fax copy of this authorization to be as valid as the original.