Pre-Employment and Employment Inquiry Consent Form

* = Required Information

In applying for employment at MHA, I give consent for inquires to be made on my history and records to include motor vehicle, criminal, educational, and social security status and history, as well as inquiries into federal and State registries, to include NC Health Care Registry, Sex Offender Registry, and other agencies regarding my background as needed. I also give consent for MHA to contact personal and professional references provided for reference checks. I understand that this information contains personal information to include any previous legal charges and convictions, driving record, work experience and habits, character reference, and educational performance and completion of degrees. I also understand that MHA holds the right to conduct ongoing Criminal Record Checks and other inquires while I am an employee/independent contractor as outlined in this description of inquires.

I authorize, without reservation, any party or agency contracted by MHA to perform inquires.

First Name *

Middle Name

Last Name *

Maiden Name *

Date of Birth *

Social Security Number *

Driver’s License Number

State of Driver License

Current Address *

City *

State *

Zip *

County *

Length at Current Residence

Previous Driver’s License (if moved within the last year)

Dates of residences with Counties and States within the last ten years:

Dates of Residence

County

State

Dates of Residence

County

State

Dates of Residence

County

State

Dates of Residence

County

State

Name of Educational Institution

City

State

Degree

Date

Applicant’s Name *

Date *