Information Reports

Tell Us About Yourself

Disclosure of Background Investigation

Rights and Acknowledgments

Authorization and Consent to Background Investigation In conjunction with your (a) application for employment, and if you are hired, at any time during your employment, your promotion, reassignment, or retention; (b) volunteer position; (c) work to be performed under contract or third party assignment; and/or (d) qualifying for a business transaction ("Engagement"), Heart to Heart Hospice ("Company") will use the services of an outside consumer reporting agency and may obtain a "consumer report" or "investigative consumer report" (collectively, "background reports") about you, including information relating to your work history and qualifications, personal background, character, general reputation, personal characteristics, professional standing, and/or mode of living. This agency will provide a written report of its findings to Company. Company uses Employment Screening Resources ("ESR"), a consumer reporting agency, to perform its Engagement related background investigations.

ESR collects various types of information to prepare background reports that may include, but are not limited to, domestic and international: criminal records, civil records, sex offender databases, employment records, education records, professional credential and license records, department of motor vehicle records ("driving records"), military records, credit reports, professional and personal references, government sanctions and exclusions databases, drug and occupational health screening results, and where it applies to the position; DOT regulated employer records in compliance with 49 CFR 382.413 and/or Pilot Records Improvement Act records in compliance with 14 CFR parts 121, 125 and 135.

You may request more information about the nature and scope of any investigative consumer reports by written request to: at Heart to Heart Hospice

First Name: Lafeada

Last Name: Jones

I currently live in the country of: US

I currently live in the state of: TX

I will be working in the state of: TX

I will be working in the city of: Dallas

I acknowledge receipt of the FCRA summary of rights Check here to receive a free copy of any employer requested Reports By signing my name below, I hereby agree, authorize and consent to the (a) the preparation of consumer reports and investigative consumer reports ("background reports") about me by Employment Screening Resources (the "Agency" or "ESR"), a consumer reporting agency, as described in the Disclosure of Background Investigation, and (b) procurement of background reports about me by Heart to Heart Hospice ("Company"), which I understand may contain information about my character, general reputation, personal characteristics, and/or mode of living. I authorize, subject to any applicable laws protecting my privacy, any local, state, federal or international law enforcement agency; public or private agency; administrator; public or private institution, public or private school or university; information services bureau; employer; insurance company; credit bureaus; or any other party holding information under my name to furnish any and all background information requested by ESR for the purpose of providing background reports to Company. I acknowledge the information that can be disclosed to the Agency, if and as allowed by law, includes, but is not necessarily limited to, information concerning my employment and earnings history, education, motor vehicle history, criminal history, professional credentials and licenses. I agree, authorize and consent to the release and disclosure of any and all information about me by ESR to Company, and where Company is pursuing my direct or temporary Engagement with a third party, Company may provide that third party with a copy of my Report.

This authorization electronically or physically signed by me shall be valid from the date of execution and throughout any subsequent association with Company as allowable by law. I agree that a copy of this document by fax or other electronic means shall be as valid as the original. 7/3/2018

Signed By:

Lafeada Jones

Date:

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