Authorization to Release Information
I have applied for a position with Safe Harbor Care Services. I have been
requested to provide information for their use in reviewing my background and
qualifications. Therefore, I hereby authorize the investigation of my past and present work character, education, military and employment qualifications.
I authorize the release of my information to Safe Harbor Care Services whether the information is of record or not, and I do hereby release all persons, agencies, firms, companies, etc., from any damages resulting from providing such information.
This authorization is valid for 180 days from the date below. Please keep this copy of my release request in your files.
Consent for Drug/ Alcohol Screen Testing
If you are offered and accept employment with Safe Harbor Care Services, in the interest of safety for all concerned, you will be required to take a urine test for drug and / or alcohol screening.
I have been fully informed of the reason for this
urine test for drug and/or alcohol screening. I fully understand what I am being tested for, the procedure involved, and do hereby freely give my consent. In addition, I
understand that the results of this test will be forwarded to my potential employer and become part of my record.
If this test is positive and l am not hired. I understand that I will be given the opportunity to explain the results of this test.
I hereby authorize these test results to be released to:
Safe Harbor Care Services
Safe Harbor Care Services -IS AN EQUAL OPPORTUNITY EMPLOYER
I certify that the information in this application is accurate, current and complete. I understand that incorrect statements or omission may result in disqualification from further consideration or termination of employment.
I authorize Safe Harbor Care Services to investigate my employment history, credentials and to obtain any relevant information (including a criminal background check) needed to make an employment decision.
I authorize Safe Harbor Care Services to disclose this application along with any information about me obtained through reference checks or during the course of the interview process for state, federal, contractual or accreditation audit purposes.
I also authorize Safe Harbor Care Services to
disclose any of my performance Appraisals, disciplinary record, or skills test for the same
purpose as above.
I release Safe Harbor Care Services and any individual or entity providing information to Safe Harbor Care Services from all liability for any damages from the disclosure of this information.
I also understand and agree that:
- Passing a medical examination and / or participating in a post-conditional offer medical
screening may be required. If medical restrictions cannot be reasonably accommodated. I
may not be hired, or if hired, employment may be terminated.
- Subject to applicable state laws, Safe Harbor Care Services reserves the
right to conduct drug screening and testing for reasonable suspicion at anytime during
employment and as a pre-employment requirement. Any violation of this policy shall
result in an applicant not being hired or an adverse employment action up to including
immediate termination. Safe Harbor Care Services has the right to change
this policy at any time as it requires.
- I understand that nothing contained in this employment application or in granting of an
interview creates an employment contract between Safe Harbor Care Services and me for either employment or for the providing of any benefit. No promises
regarding employment have been made to me. If an employment relationship is
established, I understand that my employment will be terminable at will”, that I will
have the right to terminate my employment at any time.
- I understand that should I become employed by Safe Harbor Care Services
my work assignment, schedules and / or work locations are subject to change according
to the needs of the business and the clients of Safe Harbor Care Services.