CNA Training Course Application

Bethany Retirement Living is an Equal Opportunity Employer
201 University Dr. S., Fargo, ND 58103 (701) 239-3000

APPLICANT DISCLOSURE AND RELEASE FOR BACKGROUND CHECKS, DRUG SCREENING, AND REFERENCE INFORMATION

Having made application for the CNA Class with Bethany Retirement Living, and desiring them to be informed as to my previous record and character, I hereby authorize Bethany Retirement Living and its authorized representatives to obtain information relating to my activities from educational institutions, licensing agencies and all persons or entities named on my application. This information may include, but is not limited to, academic, achievement, performance, attendance, personal history, discipline and conviction records. I hereby direct you to release such information upon the request of the bearer.

Further, I release any and all individuals and organizations, including record custodians, from any and all liability for damages of whatever kind or nature because of furnishing said information.

In connection with my application for the CNA Class with Bethany Retirement Living, I also understand that background checks will be performed by Bethany Retirement Living. I understand that acceptance in the CNA Class is conditional on the results of the background information. The background information will be obtained through:

ADVANTAGE CREDIT BUREAU
115 North University Drive, Suite 5, Fargo, ND 58102
Toll free phone: 1-800-568-4478 / Fax: 701-239-9963

I understand the information obtained from a background check may include my past employment history, criminal history and driving record. I further understand that the background information is not limited to the current state of my residence, but may include information from any other state where I have resided.

I authorize all persons and companies contacted by Bethany Retirement Living or its representatives to provide the requested background information. I understand and agree to release the aforesaid from any liability for collecting my background information.

I understand that if adverse action is taken by Bethany Retirement Living based on the results of my criminal background check, I will be given notice orally, in writing, or electronically of such adverse action. I further understand that I may request in writing within a reasonable period of time, a complete disclosure of the nature and scope of the background investigation. I also understand that I have the right to dispute the accuracy or completeness of any information furnished by the reporting agency. I further understand that the reporting agency supplying the information does not make the decision to take adverse action and cannot give specific reasons for the adverse action, only Bethany Retirement Living makes such a decision.

I agree that this Disclosure and Release will be valid, now or in the future, in original, faxed, copied or electronic form.

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