Ascension Health
CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK IN COMPLIANCE WITH THE FCRA and the DPPA.
(Fair Credit Reporting Act and the Federal Driver's Privacy Protection Act)

Driver's Lic #:
State Issued: (If no Driver License, please select NONE.)

Last Name: First Name: Middle Initial:

Maiden or Other Name Used:

Current Address: City: County: State: Zip Code:

Date of Birth:
Social Security Number:
Male/Female:


This authorization and consent for release of personal information acknowledges that Ascension Health and/or its agent, Evolution Consulting LLC, may now, or at any time I am assigned to, volunteer with or am employed by Ascension Health, conduct investigations whether the records are of a public, private or confidential nature. These investigations might include, but are not limited to, searches of educational institutions attended; financial or credit institutions, including records of loans; records of commercial or retail credit agencies; other financial statements; records of previous employment, including work history, efficiency ratings, complaints and grievances filed by or against me; records and recollections of attorney-at-law or of other counsel, whether representing me or any other person (in either a civil or criminal case in which I have been involved); records from the U.S. Veterans' Administration; criminal history information of file in local, state or federal agencies; and motor vehicle records, and following an employment offer, workers' compensation reports from either the Department of Labor, National Personnel Records or the Industrial Commission or similar agencies under the provisions of the Fair Credit Reporting Act 15, USC section 1681 et seq. I also authorize the National Personnel Records Center, or other custodian of my military service record, to release to Evolution Consulting LLC, the following information and/or copies of documents from my military service record: DD214, service record, and any disciplinary records.

I understand that these searches will be used to determine work assignment or employment eligibility under the Ascension Health employment or volunteer policies. Therefore, I authorize and consent for full release of records to the authorized representatives of the Ascension Health. In addition, I release and discharge the Ascension Health and its agent and associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs expenses or any other charge or complaint filed with any agency arising from retrieving and reporting this information. I understand that according to the Federal Fair Credit Reporting Act, I am entitled to know whether employment was denied based upon the information obtained and to receive, upon written request, a disclosure of the background report.



The following are my responses to questions about my criminal record history (if any) with descriptions to any question with a YES answer: Choose YES or NO.


1. Have you ever been convicted or plead guilty before a court of any federal, state, or municipal criminal offense? (Excluding minor traffic violations)

If YES, please provide an explanation below:



2. Have you ever received deferred adjudication or similar disposition for any federal, state or municipal criminal offense?

If YES, please provide an explanation below:



3. Have you ever received probation or community supervision for any federal, state or municipal criminal offense?

If YES, please provide an explanation below:



4. Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States?

If YES, please provide an explanation below:



5. As of the date of this authorization, do you have any pending criminal charges against you?

If YES, please provide an explanation below:



THIS SECTION IS TO BE USED TO LIST ALL COUNTIES AND STATES OF RESIDENCE SINCE AGE 18 OR HIGH SCHOOL GRADUATION. YOU MUST BE SPECIFIC ABOUT DATES OF RESIDENCE.
City/Town
 County
 State
 Date From
 Date To



























I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS AUTHORIZATION IS TRUE, CORRECT AND COMPLETE. I UNDERSTAND THAT IF ANY INFORMATION PROVES TO BE INCORRECT OR INCOMPLETE THAT GROUNDS FOR THE CANCELING OF ANY AND ALL OFFERS OF EMPLOYMENT OR VOLUNTEER POSITIONS WILL EXIST AND MAY BE USED AT THE DISCRETION OF THE EMPLOYER.


I have read, I understand and agree to each of the disclosures, authorizations, directions and indemnifications. My typed name below shall have the same force and effect as my written signature.