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Background Check Consent Form

As a prospective employee of Revival Research Institution (“the Agency”) I understand that it is the Agency’s policy to secure conviction criminal history information as a part of their pre-employment screening process.

I authorize the Agency to use the information for the sole purpose of verifying that the applicant is allowed to work in the Healthcare field.

This field is for validation purposes and should be left unchanged.

Applicant Name

Date of Birth(Required)
Clear Signature
Date(Required)