Employment reference authorization form

Employment Reference Authorization Form

WASHINGTON POISON CENTER

APPLICANT INFORMATION

Full Name(Required)

Date of Birth (for identification purposes only)(Required)

Address(Required)

Street Address City State ZIP Code

Phone Number(Required)

Email(Required)

Position Offered(Required)

AUTHORIZATION
I, the undersigned, authorize the Washington Poison Center to conduct a comprehensive employment background check and contact my past and present employers, references, and other sources for the purpose of verifying the information I have provided on my employment application and resume.
I understand that the information collected will be used solely for evaluating patient safety and my suitability for employment and will be handled with the utmost confidentiality in accordance with applicable laws and regulations.

REFERENCES

Please list at least three professional references below.

Most current previous employer:(Required)

Supervisor(Required)

Dates Employed from:(Required)

to:(Required)

Phone(Required)

Email(Required)

Previous employer or other professional reference:(Required)

reference type(Required)

Dates Employed from:(Required)

to:(Required)

Phone(Required)

Email(Required)

Previous employer or other professional reference:(Required)

Reference type(Required)

Dates Employed from:(Required)

to:(Required)

Phone(Required)

Email(Required)

ACKNOWLEDGMENT AND SIGNATURE I certify that the information provided on this form is true and correct to the best of my knowledge. I understand that any false statements or omissions may result in disqualification from employment or termination if already employed.

Signature(Required)

Adding your name is considered a signature.

Date(Required)

FOR OFFICE USE ONLY

Received by:

Date: