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Authorization of Release of Information

I have applied for employment with NEBRASKA CARE. As part of the application process, I completely understand the reasons and potential uses of such investigation. I authorize NEBRASKA CARE to use any and all information acquired to make decisions regarding my employment. Further, I understand and agree that NEBRASKA CARE, may request information, orally or in written form; from various agencies, including public and private sources concerning my past activities relating to my previous employment, education, criminal history, credit reports, driving record, civil matters, as well as other experiences and waive any right under law concerning notification or waive any right to receive a copy of any written statement. I agree to provide my date of birth in order to complete this application. I hereby give my authorization to release any requested documents to any facility that I may work in. I release Nebraska Care and their agents from all liability in regard to any information obtained about me in the course of their background check. In the event a law does not provide for prospective employers to have access to information, I hereby delegate NEBRASKA CARE as my agent for the receipt of information. For the purpose of quality assurance and control I further authorize any form of audio/video recording during the interview, orientation, disciplinary, employment, termination and any other reasons in which myself and NEBRASKA CARE, and its clients are involved or when Nebraska Care deems appropriate during the course of my employment. I also understand that I may have to submit a urine, blood, and/or hair sample to be tested. The drug tests can be conducted and collected at any time of the application process, employment, incident reporting and / or injuries involving myself or Random Drug Screen. I understand that the drug screening is not the sole determining factor for employment. I further consent an on-going release of authorization for any information to which my employment is a concern from background checks and drug screens. I acknowledge that a telephonic facsimile (fax), copy of this release or electronic copy shall be as valid as the original. This release is valid for all persons and private entities, all federal, state, county, and local agencies and authorities. I understand that any false Information in this application shall be reason for rejection of my application or termination of employment. I also understand that any legal controversy or legal claim arising out of or in relation to this application, excluding legal action taken by NEBRASKA CARE, to collect our fees and/or recover damages for, or obtain an injunction relating to the site operations, intellectual property, and our services, shall be resolved in an arbitration under the Federal Arbitration Act and before the American Arbitration Association (AAA) in accordance with AAA’s then obtaining Commercial Arbitration Rules at the AAA location closest to NEBRASKA CARE oﬃce. The administrative cost of the arbitration and the arbitrators fee shall be shared by the parties. The employment relationship between NEBRASKA CARE and the employee is terminable at will, with or without notice, with or without cause. I hereby acknowledge, removal from the eligible list, and/or disqualification of temporary employee, intern, volunteer, or contract employee.

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Authorization of Release of Information

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