Priority Medical Group Background Investigation Release

I, the undersigned, do hereby authorize Priority Medical Group, to conduct a background investigation into the following areas of my employment history: current and previous employment, education including professional certificates or degrees, criminal and civil records.

AUTHORIZATION & RELEASE:

I hereby authorize any person, agent, corporation, company, agency, or institution, to release any information, documents, or assessments they possess or my performance as an employee, student, associate or acquaintance.
I release, and permanently hold harmless, Priority Medical Group, their agents and assigns, from demands and or liabilities that may originate from these investigations, conducted by them or their agents, any person, corporation, company, institution that may act upon the authority of this release.
I hereby authorize that a photocopy or electronic facsimile of this document shall serve as an original. If a Notarized copy of this document is required for background check, the notarized copy will be provided.

Applicant General Information:

Full Name*

First Middle Last

Date of Birth*

Social Security Number*

Sex*

Current Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Length of time at current address:*

*If less than 5 years please provide previous addresses.

Previous Address #1:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Length of time at Previous Address #1:

Previous Address #2:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Length of time at previous address #2:

Applicant Signature*

Print Name*

Date Signed*

Captcha

Please fill out the captcha to complete your application.

Priority Medical Group Background Investigation

Priority Medical Group Background Investigation

Priority Medical Group Background Investigation Release

AUTHORIZATION & RELEASE:

Applicant General Information:

Powerful, Personalized Care