Wake Forest Baptist Medical Center - Applicant Consent Form

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Authorization for Release of Information & Records

I understand that in consideration of my application, an investigation will be conducted. I authorize Wake Forest University Baptist Medical Center, through its agent, Investigative Associates & Consultants, Inc., to conduct such an investigation and release the organization and its agent, including its officers, employees, and representatives, from all liability or responsibility for this investigation, which may include, but not be limited to, the gathering of information regarding verification of prior employment, references, consumer credit history, driving history, and any criminal history which may be in files of any state, federal, or local criminal justice agencies ("investigative reports")

I further understand that at any time during the course of my employment, Wake Forest University Baptist Medical Center through its agent, Investigative Associates & Consultants, Inc., in accordance with all applicable state and federal law, may obtain additional or supplemental investigative reports to be used in connection with my retention as an employee at Wake Forest University Baptist Medical Center.

Moreover, I understand that I have the right to request, in writing, a complete and accurate disclosure of the nature and scope of this investigation. I understand that the information requested below regarding sex, race, date of birth, and maiden name is for the sole purpose of gathering information accurately.

Personal Information:

no dash (-)
 (MM/DD/YYYY)
(Please print Full Birth Name – Do not use initials)
 Maiden, Previous Married, and all other
  List any other last names in the past 7 years

Current Address: