Employment Background Authorization | Right Path Behavior Health Services

Form I.D.*
Name
First Middle Last
Please list all other names used:
Social Security Number
Sex
Date of birth
Race
Address
Current Address City State / Province / Region ZIP / Postal Code
Years at Residence
Drivers License Number
State Issued
State / Province / Region
Previous Address
Current Address City State / Province / Region ZIP / Postal Code
Years at Residence
Accurate Information & Background Authorization Acknowledgement
I state that the information above is accurate to the best of my knowledge. I also understand that the information about by background may contain negative information about my character and style of living. This release any liability against the company or its against agents. The authorization may be used in copy form.
Name typed below will serve as signature, legally binding this agreement*
First Last
Today's Date*

Accurate Information & Background Authorization Acknowledgement