I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
I understand that as part of LRS Healthcare procedure for processing my documents for potential employment, or for otherwise determining my eligibility for a position, LRS Healthcare may obtain a background check at any time for employment purposes. This report may include information as to my references, past employment, educational background, and criminal background, whichever may be applicable. This information may be acquired by contacting, either directly or indirectly former employers, coworkers, educational institutions, and public agencies.
I hereby authorize LRS Healthcare, to release any and all professional credentials, work verifications, criminal background check information and/or health information that have been acquired by LRS Healthcare. I understand this information will be sent only to the clients where I will be presented for potential assignment and/or working as an LRS Healthcare employee, for the purpose of assuring that all required credentials and regulatory documentation as required by contract are in place and current prior to and during my assignment. I hereby release LRS Healthcare and affiliates, schools, companies, former employers and all other persons named from all liability for any damages resulting from issuing this information.
Please enter your name in the box below. By doing so you are hereby certifying that you are indeed the person listed above and signing this form.
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