Background Check & Education Verification Disclosure & Authorization

Background Check Authorization and Education Verification

Thank you for your interest in the McNabb Center! Your authorization is required for us to process your application for employment or student placement. It is also required to complete required background checks and to verify your education and applicable licenses/certification before and during employment/placement. Employment at McNabb is contingent upon a clean drug screen, background check, and driving record. Please complete the following information and electronically sign to authorize the McNabb Center to conduct these checks. NOTE: Please use your legal name for all details.

"*" indicates required fields

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ACKNOWLEDGEMENT*

I hereby acknowledge that I have received and read the disclosure statement below.

Disclosure Statement
This is to inform you that as part of the McNabb Center’s procedure for processing your employment or student application, or during the course of your employment, the McNabb Center may obtain information from a consumer reporting agency or verification service, a criminal background check, motor vehicle report, drug screen or confirmation of education, licenses or certifications. If such an investigation is made, you have the right to make a written request within a reasonable period of time to receive additional, detailed information about the nature and scope of this investigation.

McNabb Center will not obtain such a report without your signed authorization. The McNabb Center complies with the Fair Credit Reporting Act, which provides consumers with rights regarding consumer reports and which places specific obligations on employers using consumer reports.

If you are required to submit to a fingerprint background check it will be used to check the criminal history records of the Tennessee Bureau of Investigations (TBI) and Federal Bureau of Investigations (FBI).

Full Legal Name*

Today's Date*

MM slash DD slash YYYY

AUTHORIZATION

Name*

First Name Full Middle Name Last Name

Other Names Used including Maiden (separate with a comma)

Date of Birth*

Month

Day

Year

Social Security Number*

Please enter a number greater than or equal to 9.

Daytime Phone*

Alternate Phone

Email*

Name as it appears on your driver's license or State ID

First Middle Last

Driver's License Number*

State of Issuance*

Gender Indicated on Driver's License*

Female

Male

Race / Ethnicity*

Native American or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White or Caucasian

Two or more races

Hispanic or Latino

I decline to identify my race / ethnicity

Other

List your last 5 addresses including street address, city, state, zip, county and dates living in that location. If you have lived in less than 5 locations, write N/A.

CURRENT ADDRESS

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

County*

Dates at this address (From when to when, e.g.: Dec. 2021 to June 2022)*

ADDRESS BEFORE THE CURRENT ADDRESS

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

County

Dates at this address (From when to when, e.g.: Dec. 2021 to June 2022)

ADDRESS BEFORE THE LAST ADDRESS

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

County

Dates at this address (From when to when, e.g.: Dec. 2021 to June 2022)

ADDRESS BEFORE THE LAST ADDRESS

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

County

Dates at this address (From when to when, e.g.: Dec. 2021 to June 2022)

ADDRESS BEFORE THE LAST ADDRESS

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

County

Dates at this address (From when to when, e.g.: Dec. 2021 to June 2022)

EDUCATION VERIFICATION

Please complete the following information based on the highest level of education you have completed.

Highest Level of Education Completed

GED

High School Diploma

Associates

Bachelors

Masters

Doctorate

MD/DO

LPN

RN

APRN

Other

University or institution where you acheived your highest level of education?*

City and State of University/Institution*

Major/Degree Title*

Name as it appears on diploma*

Date of Graduation*

Have you received more than one degree in the last 5 years?

Yes

No

Level of Education Completed

GED

High School Diploma

Associates

Bachelors

Masters

Doctorate

MD/DO

LPN

RN

APRN

Other

List additional degree if obtained in the last 5 years

University or institution where you acheived this degree.*

City and State of University/Institution*

Major/Degree Title*

Name as it appears on diploma*

Date of Graduation*

Today's Date*

MM slash DD slash YYYY

Authorization

By checking this box and typing my full name below I hereby authorize Helen Ross McNabb Center to conduct all necessary background checks and verifications for employment or student placement.

Full Legal Name

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