Volunteer Handbook - Roper St. Francis Healthcare

NOTICE/AUTHORIZATION AND RELEASE FOR THE PROCUREMENT OF ACONSUMER AND/OR INVESTIGATIVE CONSUMER REPORTI authorize Roper St. Francis Healthcare to verify all information within the Volunteer Application. I further understand thatRoper St. Francis Healthcare has contracted with HirEase Corporation to procure certain consumer and/or investigativeconsumer reports, as necessary, for use with its verification process to include a criminal background check, i.e., any criminalrecord information which may be in the files of any Federal, State or Local criminal justice agency in any State. I understandthat the results of this verification process will be used to determine my volunteer eligibility.I consent to the release of consumer and/or investigative consumer reports, as defined above, in connection with my applicationto volunteer at Roper St. Francis Healthcare. I further understand that this consent will apply during the course of time that Ivolunteer at Roper St. Francis Healthcare and that such consent will remain in effect until revoked in a written document signedby me. In the event that I wish to refuse or revoke my consent at any time, I understand that I may do so. I further understandthat Roper St. Francis Healthcare is relying on the information contained in my Volunteer Application, this Notice/Authorizationand Release and information otherwise disclosed to Roper St. Francis Healthcare by me, as true and correct information, and mayuse such information when verifying information, obtaining consumer reports and/or investigative consumer reports.According to the Fair Credit Reporting Act, if any adverse decision is made with regard to my application to volunteer, basedentirely or in part on the information contained in a consumer report or investigative consumer report, I understand that I amentitled to receive a copy of this report upon written request, and a disclosure of the nature and scope of the report.The Identifying Information for Consumer Reporting Agency is considered Confidential Information and will only be providedto designated personnel.I agree to release Roper St. Francis Healthcare, Hirease Corporation, and their associates from any and all claims and/or damagesarising from retrieving and reporting information per this Agreement.I acknowledge that I have carefully read the above Notice/Authorization and Release and, by typing or signing myname below, signify that I understand and agree to the terms and conditions therein.Signature: ___________________________________________Date: ________________IDENTIFYING INFORMATION FOR CONSUMER REPORTING AGENCY(Please fill out all information below. Without this information, we will be unable to properly identify you in the event wefind adverse information during the course of our background investigation.)Applicant Name: (First Middle Last)Current Address: (street address)Other Name(s) Used: (like Maiden) City: State: Zip:Social Security Number: Former Address: (1)Sex: Race: City: State: Zip:Month, Day and Year of Birth: Former Address: (2)City: State: Zip:A photocopy or telephonic facsimile (Fax) of this Notice/Authorization and Release shall be as valid as the original.