Associate Medical

Applicants

Release and Consent for Background Check

Complete Form

Associate Medical Professionals, Inc.
5116 N. Portland • Suite 100 • Oklahoma City, OK

I authorize Associate Medical Professionals to contact and obtain information about me from any or all of my references, former employers, educational institutions, persons, and law enforcement agencies, and to make inquiries about me, my employment and/or educational background. I release Associate Medical Professionals, its employees and all other persons and corporations from all liability and responsibility arising out of such inquiry or the response to such inquiry.

Further, I authorize the procurement of investigative and criminal reports and understand that such report may contain information as to my background and reputation. Further information may be available upon request and this authorization shall be valid for this and any further requests. I acknowledge that a telephone facsimile or photographic copy of this consent shall be as valid as the original.

I understand that Associate Medical Professionals may utilize a Consumer Reporting Agency to procure background information about me. If so, I understand I have certain rights under The Fair Credit Reporting Act which can be viewed at the Federal Trade Commission’s website (http://www.ftc.gov).

In the event that information from the report is utilized in whole or in part in making an adverse decision with regard to your potential employment, before making the adverse decision, Associate Medical Professionals will inform you as to the type of report as well as the name, address and phone number of the Consumer Reporting Agency. If you request in writing within a reasonable period of time, we will provide you with a copy of the report as well as a complete and accurate disclosure of the nature and scope of the information requested. Such disclosure will be made to you within five (5) days of the date on which we receive the request from you or within five (5) days of the time the report was first requested.

I acknowledge that I have received a copy of this release and consent. I hereby authorize Associate Medical Professionals to conduct a background check and to obtain a consumer report in order to consider me for employment.