Background Check Release Form

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Kindly submit the following information in the form below:

I hereby authorize ClearSTONE GROUP, LLC and its designated agents and representatives to conduct a comprehensive review of my background through a consumer report and/or an investigative consumer report to be generated for employment, promotion, reassignment or retention as an employee. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas: Verification of Social Security Number, current and previous residences, employment history including all personnel files, education, character references, credit history and reports, criminal history records from any criminal justice agency in any or all federal, state county jurisdictions, birth records, motor vehicle records to include traffic citations and registration and any other public records.

I authorize the complete release of these records or data pertaining to me which an individual, company, firm, corporation, or public agency may have. I understand that I must provide my date of birth to adequately complete said screening, and acknowledge that my date of birth will not affect any hiring decisions. I hereby authorize and request any present or former employer, school, police department, financial institution or other persons having personal knowledge of me, to furnish bearer with any and all information in their possession regarding me in connection with an application for employment. This authorization and consent shall be valid in original, fax, or copy form. I hereby release ClearSTONE GROUP, LLC and its agents, officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from all liability for damages of whatever kind, which may at any time, result to me, my heirs, family or associates because of compliance with this authorization and request to relapse.

I understand that a copy of this authorization may be given to me at any time, provided I request it in writing. Information on this application and results of the background investigation will be maintained in confidence in accordance with company hiring practices.

Name

Print All Former Names Used

Social Security Number

Sex

Race

Date of Birth

Current Street Address

City

State.

Zip

Driver's License Number

State of Issuance

Phone Number

Employer Name

Address

May we contact your employers

Yes No

Supervisors

Print Residences in the previous 10 years (City & State) City

Address

State

City

Address

State

City

Using the numbers below, please indicate whether you have been convicted of any crimes listed below:

01. Homicide/Murder
06. Destruction of Property
11. Fraud
02. Rape or Molestation
07. Drug Trafficking/Use or Possession
12. Prostitution
03. Burglary/Robbery/Larceny

08. Child Abuse/Domestic Violence
13. Other
04. Threats of Harassment
09. Public Intoxication/Drunk & Disorderly Conduct
05. Assault or Fighting
10. Theft/Receiving Stolen Goods

Number of Violation(s)

Status/Disposition

Applicant Signature

Date

Don’t Hesitate to Call Us Today! 407-462-7233

Don’t Hesitate to Call Us Today! 407-462-7233

Background Check Release Form

Reach Out to Us

Contact Details

1800 PEMBROOK DRIVE, SUITE 300 ORLANDO, FL 32810

Phone Number:
407-462-7233

Email Address: emichel@mybellacare.com

Bella Group Home

Clearstone Main Office

Bella Senior Living

Valuable Resources

Let's Get Started

01

Payment

Accepted

02

Send Your

Referrals

03

Client Satisfaction

Survey

04

Meet Our

Staff

Don’t Hesitate to Call Us Today! 407-462-7233

Don’t Hesitate to Call Us Today! 407-462-7233

Background Check Release Form

Reach Out to Us

Contact Details

1800 PEMBROOK DRIVE, SUITE 300 ORLANDO, FL 32810

Phone Number: 407-462-7233

Email Address: emichel@mybellacare.com

Bella Group Home

Clearstone Main Office

Bella Senior Living

Valuable Resources

Let's Get Started

01

Payment

Accepted

02

Send Your

Referrals

03

Client Satisfaction

Survey

04

Meet Our

Staff

Phone Number:
407-462-7233