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           I,
 
hereby give (HEALTHSOURCE GROUP) my permission to conduct an investigation to obtain information which the Company thinks its necessary to determine my qualifications for employment with the Company, including but not limited to, my permission to contact any former employer, any personal or professional reference,  any police department, law enforcement agency or organization, or any other local, state or federal government agency or any other appropriate source or individual for the purpose of gathering information, personal or otherwise, that such sources may have relating to my character, general reputation, or criminal records, and I give consent to any source to release to the company whatever information they have about me.
I understand that the information requested about me on this form is necessary so that accurate information is obtainable.  I hereby consent to this investigation and authorize HEALTHSOURCE GROUP to procure reports on my background as stated above regarding criminal background checks and drug screenings.  I also unconditionally release all named and unnamed sources from any and all liability which might result from furnishing any information about me.
   
Print Name:
   
Current Address:
   
City/State/Zip:
   
Previous Address :
   
City/State/Zip:
   
Country:
   
SSN# :
   
*Date of Birth:
   
Drivers License # :
   
State:
   
If Never Licensed, Please Indicate:
   
 
 
 
 
HSG Witness Name (Please Print): 
   
HSG Witness Signature:
    * used for accurate information retrieval