Background Check Consent — FORWARD ETHOS

Tell Us About Yourself

Name

First Name

Last Name

Professional Bio

Please include your preferred pronouns, any community of allyship, area of specialization

Preferred Population

Please include ages, individuals/couples/families, diagnoses or issues, etc.

Modalities you are trained in:

Please list all modality you are trained in, as well as number of supervision hours.

Earliest Start Date

MM

DD

YYYY

Available Schedule

Please include days and time that can be consistently be allocated to clients.

Date of Birth

MM

DD

YYYY

Last 4 Digits of Social Security

Professional License Number

Phone

(###)

###

####

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reference Name #1

First Name

Last Name

Phone

(###)

###

####

Email

Reference Name #2

First Name

Last Name

Email

Phone

(###)

###

####

I have read the Consent for Pre-Employment Reference and Background Checks terms below. I consent to Forward Ethos Counseling use of the disclosed information to conduct a background and reference check. I authorize all persons who are the custodians of these records, or who may have information relevant to my application for employment, to provide records or disclose such information to Forward Ethos Counseling and/or its designated representative.

Yes

Consent for Pre-Employment
Reference and Background Checks

I recognize that any offer of employment made to me by Forward Ethos Counseling is conditional upon reference and background checks which are acceptable to the company, and that information obtained during this process may result in my not being employed by Forward Ethos Counseling .

I understand that Forward Ethos Counseling and/or its designated representatives will conduct pre-employment reference and background checks thoroughly and within the confines of all applicable state and federal laws.

I understand that Forward Ethos Counseling will maintain any information obtained as a result of my signing this Consent in a confidential file in the Human Resources Department. I understand that a reference and background check is being performed as part of the process to evaluate me prior to any offer of employment, and is not conducted for any other purpose.

I authorize Forward Ethos Counseling , or its designated representative presenting this consent or a photocopy thereof, to obtain the following records and information in connection with my application for employment with the company insofar as the records and information are relevant to the position for which I am applying:

Criminal History and Convictions
Motor Vehicle Operation
Certification and Licensing
Educational History and Credentials
Employment Eligibility
Prior Employment Information
Professional References

If the position for which I am applying specifically requires a personal credit history acceptable to Forward Ethos Counseling , I understand that I will be required to sign a separate Fair Credit Reporting Act Consumer Report Disclosure authorizing Forward Ethos Counseling to obtain the same. No personal credit history will be obtained by Forward Ethos Counseling without this authorization.

Disclaimer
The contents of the below form is confidential and intended for Human Resource use only. This information will not be shared outside of this use, without a written consent of the applicant.

Thank you for applying to work at Forward Ethos.

Tell Us About Yourself