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Virginia Dare Behavioral Health Services Inc

“A Community Healthcare Provider”


Staffing/Intern
Disclosure to Employment Applicant
Regarding Procurement of
A Consumer Report

In connection with your application for employment, the Virginia Dare Behavorial Health
Services Inc may procure a Background Investigate Report on you as part of the process of considering
your candidacy as an employee. In the event that information from the Reports is utilized in whole or in
part in making an adverse decision with regard to your potential employment, before making the adverse
decision, VDBHS Inc will provide you with a copy of the Report and a description in writing of your
rights under the federal Fair Credit Reporting Act.

The Fair Credit Reporting Act gives you specific rights in dealing with consumer reporting
agencies. You will be given a summary of these rights together under with this document.
By your signature below, you hereby authorize Virginia Dare Behavorial Health Services Inc to
obtain a Background Investigative Report s and/or Criminal about you in order to consider you for
employment. The information requested below is used strictly for this employment screening
purpose in order to obtain accurate results. The Reports may include, but not be limited to,
criminal history, verification employment, driving records, health registry, and sex offender.

Applicant’s Name: _______________________________________________


(Please Print or type your Full Legal Name

Applicant’s Address: _________________________________________

City/State/Zip: _______________________________________________

Social Security Number: __________________________ Date of Birth: _______

 I have received a copy of my Summary of Rights Under the Fair Credit Reporting
Act. (Please check box to verify receipt.)

_______________________________________ ______ _______


Signature Date

Position title: ___________________________

Locations of Employment: 25 Lane Road


363 Lane Road Stantonsburg, NC 27883
107 Macon Street
Any participant’s residence

The information requested above is used to assist in the completion of a background investigation. The
information will be maintained in a limited access file. The information will be used for the sole purpose
of identification when conducting a background investigation.
6/30/09
Virginia Dare Behavioral Health Service Inc.
“A Community Healthcare Provider”

Criminal Background Check


(Include Criminal, DMV, Sex Offender)

VDBHS Inc. will pull one criminal record check on all applicants prior to employment with the
company.

A North Carolina (statewide) search will be done on all applicant and if resided in North
Carolina less than 5 years a nationwide search. Also VDBHS Inc. will use fingerprint cards to
fingerprint the applicant that has reside in the state for less than 5 years. The applicant’s
fingerprint cards will be mailed to State Bureau of Investigation (SBI) at 3320 Garner Road
(P.O. Box 29500, Raleigh, NC 27626-0500 for processing. The applicant’s fingerprint card is the
only means by which CIIS (Criminal Information and Identification Section) can accurately
match the applicant to the criminal record on file with CIIS. Once results are in it will be
forwarded to VDBHS Inc. If the information in the CHRI record is used to disqualify the
applicant, the official making the determination of suitability for employment shall provide the
individual the opportunity to provide additional information, or challenge the accuracy of the
information contained in the CHRI record as set out below. The individual must be afforded a
reasonable time to correct or complete this information. An individual should not be presumed to
be guilty of any charges/arrest for which there is no final disposition stated on the CHRI record.
Any individual wishing to correct, complete or otherwise challenge a CHRI record must avail
themselves of the procedures set forth in the Division of Criminal Information (DCI)
administrative procedures. (12NCAC 04F .0404)

Additional criminal background checks will only be performed if an employee reports that they
have just incurred an infraction/violation with North Carolina or Federal Law. Depending on the
type of infraction/violation will determine whether or not the employee will continue his/her
employment with VDBHS Inc.

All employees must report any infraction/violation within 5 business days.

By signing below, I have read the above information.

____________________________ _________
Applicant/Employee Date
Virginia Dare Behavioral Health Service Inc.
“A Community Healthcare Provider”

Employment Application
APPLICATION IMFORMATION

Last Name: First: M.I. Date:

Street Address: Apartment/Unit#

City: State Zip Code:

Date Available: S.S. Number: Desired Salary:

Position Applied for:

Are you a citizen of the United States? Yes No If no, are you authorized to work in the U.S.? Yes No

Have you ever worked for this company? Yes No If so, when?

Have you ever been convicted of a felony? Yes No If yes, explain?

EDUCATION
High School: Address:

From: To: Did you graduate? Yes No Degree:

College: Address:

From: To: Did you graduate? Yes No Degree:

Other: Address:

From: To: Did you graduate? Yes No Degree:

REFERENCES: Please list three professional references.


Full Name: Relationship/Company

Address Phone ( )

Full Name: Relationship/Company

Address Phone ( )

Full Name: Relationship/Company

Address Phone ( )
Virginia Dare Behavioral Health Service Inc.
“A Community Healthcare Provider”

Employment Application
PREVIOUS EMPLOYMENT
Company: Phone ( )

Address: Supervisor:

Job Title: Starting Salary $ Ending Salary $

Responsibilites:

From: To: Reason for Leaving:

May we contact your previous supervisor for a reference? Yes No

Company: Phone ( )

Address: Supervisor:

Job Title: Starting Salary $ Ending Salary $

Responsibilities:

From: To: Reason for Leaving:

May we contact your previous supervisor for a reference? Yes No

Company: Phone ( )

Address: Supervisor:

Job Title: Starting Salary $ Ending Salary $

Responsibilities:

From: To: Reason for Leaving:

May we contact your previous supervisor for a reference? Yes No

MILITARY SERVICE
Branch From: To:

Rank at Discharge Type of Discharge:

If other than honorable, explain

DISCLAMIER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge.
If the application leads to employment, I understand that false or misleading information in my application or
interview may result in my release.
Signature D ate
Virginia Dare Behavioral Health Service Inc.
“A Community Healthcare Provider”

Employee Emergency Information Form


PERSONAL INFORMATION
Employee ID
First Name
Middle Name
Last Name
Nickname
Gender
Citizenship
Place of Birth

Home Address

District/Country
Home Phone
Cellular Phone
Home Fax
Home e-mail address
Birthday (MM/DD/YYYY)
Government ID or SSN
Passport number
Driver’s License/State ID number
MEDICAL INFORMATION
Doctor’s Name

Address

Phone Number
Blood Type
Medical conditions
Allergies
Current Medications
EMERGENCY INFORMATION
Emergency contact’s name
Relationship

Address

Phone Numbers
Virginia Dare Behavioral Health Service Inc.
“A Community Healthcare Provider”

Equal Employment Opportunity Form


Application Information
Full Name: __________________________________________________________________________
Last First M.I.

Address:____________________________________________________________________________
Street Address State Zip Code

Home Phone:_(_____)___________________Social Security Number:___________________________

Position Applied for:___________________________________________________________________

Voluntary Information
This information is being requested in accordance with federal regulations. The information is voluntary and will not
be used when considering you for employment with our company.

Racial or Ethnic Group

American Indian/Alaskan Asian/Pacific Islander African American/Black

Hispanic/Latino White/Caucasian Other

Gender

Female Male

Military Service

Pre-Vietnam Era Vietnam Era

Post-Vietnam Era Disabled Veteran

How did you hear about us?

Newspaper Company Employee Professional Publication

Job Fair Placement Office Web Site

Other _________________

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