Volunteer Online Orientation - Part 4 - CHI Mercy Health

CHI – Mercy Health Mercy Medical Center (Division) #12882 - Volunteer Disclosure & Authorization

Volunteer's Name*

First Last

Applicant Full Name*

First Middle Last

Social Security Number

Date of Birth*

Current Address*

Street Address City State / Province / Region ZIP / Postal Code

Driver's License State*

Driver's License Number*

Address on Driver's License*

Street Address City State / Province / Region ZIP / Postal Code

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

The prospective organization (“the Company”) may obtain information about you from a consumer reporting agency made in connection with your application to volunteer with the Company. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment history, or other background checks. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by PreCheck, Inc., 3453 Las Palomas Rd. Alamogordo, NM 88310; 1(888) PreCheck [1-888-773-2432] or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing the Company to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your volunteering with the Company to the extent permitted by law.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Company at any time after receipt of this authorization and throughout the term of my volunteering, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by PreCheck, Inc., 3453 Las Palomas Rd. Alamogordo, NM 88310; 1(888) PreCheck [1-888-773-2432] another outside organization acting on behalf of the Company, and/or the Company itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

My present employer may be contacted for a job reference*

Yes
No

Electronically submitting a response to statements made above constitutes an electronic signature. Any record containing an electronic signature shall be deemed for all purposes to have been signed and will constitute an original when used or printed from electronic records established and maintained by CHI or its agents in the normal course of business and/or as a part of its Corporate Responsibility Program. By clicking “Submit” below, you attest that you have read, understand and voluntarily agree to provide your Acknowledgement and Certification by electronic signature. Please note that prior to completing this section and the final submission of your responses, you may change any of your responses or cancel your agreement/authorization to provide your Acknowledgement and Certification by electronic signature. Once submitted however, your agreement to provide Acknowledgement and Certification by electronic signature cannot be cancelled.

I acknowledge that I have read the above statements. I also agree to discuss any questions or concerns regarding this with my supervisor or other appropriate Catholic Health Initiatives’ leader.*

I agree
I do not agree

Email

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