??ࡱ? > ?? ? ? ???? ? ? ?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? ?? ^' bjbjO?O? u: -?c-?c? ? ?? ?? ?? ? rc rc ?q ?q ?q ?q ?q $ ???? ?q ?q ?q P -r $ Qr , ?q ڭ ? }r }r ?r ?r ?r ?s . ?s t A? C? C? C? C? C? C? $ Ư ? |? 0 g? - ?q t ?s ?s t t g? ?q ?q ?r ?r 4 ?? Ex Ex Ex t F ?q ?r ?q ?r A? Ex t A? Ex Ex ?? ? ?? ?r ???? 4???? ???? [t v S? > -? ?? 0 ڭ ?? ?? ?t ? ?? | ?? ?? b ?? ?q ? ( t t Ex t t t t t g? g? ?v ? t t t ڭ t t t t ???? ???? ???? ???? ???? ???? ???? ???? ???? ???? ???? ???? ???? ???? ???? ???? ???? ?? t t t t t t t t t rc p : DISCLOSURE REGARDING BACKGROUND INVESTIGATION Employer (?the Company?) may obtain information about you from a third party consumer reporting agency for employment purposes. Thus, you may be the subject of a ?consumer report? and/or an ?investigative consumer report? which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records (?driving records?), verification of your education or employment history, or other background checks. Credit history will only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying. You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you, and disclosure of the nature and scope of any investigative consumer report and to request a copy of your report. Please be advised that the nature and scope of the most common form of investigative consumer report is an employment history or verification. These searches will be conducted by Pre-Employ.com, Inc., Compliance Department, P.O. Box 491570, Redding, California 96049-1570, or by fax to (888) 999-3839, www.preemploy.com. The scope of this disclosure is all-encompassing, however, allowing the Company to obtain from any outside organization all manner of consumer reports throughout the course of your employment to the extent permitted by law. Signature: Date: ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that?I have read and understand both of those documents. I hereby authorize the obtaining of ?consumer reports? and/or ?investigative consumer reports? by the Employer at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Pre-Employ.com, Inc., Compliance Department, P.O. Box 491570, Redding, California 96049-1570, or by fax to (888) 999-3839, www.preemploy.com, and/or Employer itself. I agree that a facsimile (?fax?), electronic or photographic copy of this Authorization shall be as?valid as the original. California applicants only: Under California Civil Code section 1786.22, you are entitled to find out what is in the CRA?s file on you with proper identification, as follows: In person, by visual inspection of your file during normal business hours and on reasonable notice. You also may request a copy of the information in person. The CRA may not charge you more than the actual copying costs for providing you with a copy of your file. A summary of all information contained in the CRA file on you that is required to be provided by the California Civil Code will be provided to you via telephone, if you have made a written request, with proper identification, for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to you. By requesting a copy be sent to a specified addressee by certified mail. CRAs complying with requests for certified mailings shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the CRAs. ?Proper Identification? includes documents such as a valid driver?s license, social security account number, military identification card, and credit cards. Only if you cannot identify yourself with such information may the CRA require additional information concerning your employment and personal or family history in order to verify your identity. The CRA will provide trained personnel to explain any information furnished to you and will provide a written explanation of any coded information contained in files maintained on you. This written explanation will be provided whenever a file is provided to you for visual inspection. You may be accompanied by one other person of your choosing, who must furnish reasonable identification. An CRA may require you to furnish a written statement granting permission to the CRA to discuss your file in such person?s presence. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law . ?% S i g n a t u r e : D a t e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ N o t i c e R e g a r d i n g C r e d i t C h e c k s P e r C a l i f o r n i a L a w : P u r s u a n t t o S e c t i o n 1 0 2 4 . 5 o f t h e C a l i f o r n i a L a b o r C ode, the Company informs you that it may obtain a credit report about you from the above named entity, because you are seeking to work in the following position: [_] An employee covered by the executive exemption set forth in subparagraph (1) of paragraph (A) of Section 1 of Wage Order 4 of the Industrial Welfare Commission; [_] A position in the state Department of Justice; [_] A sworn peace officer or other law enforcement; [_] A position for which the information contained in the report is required by law to be disclosed or obtained; [_] A position that involves regular access to specified personal information for any purpose other than the routine solicitation and processing of credit card applications in a retail establishment, such as bank or credit card account information, social security number, or date of birth; [_] A position which the person can enter into financial transactions on behalf of the company; [_] A position that involves access to confidential or proprietary information; [_] A position that involves regular access to $10,000 or more of cash; or [_] The Company will not obtain a consumer credit report on you. BACKGROUND INFORMATION Last Name First Middle Other Names/Alias Social Security* # Date of Birth* Driver?s License # State of Driver?s License** Present Address City/State/Zip Phone Number ___________________________ Former Employer Position Dates of Employment *This information will be used for background screening purposes only and will not be used as hiring criteria. 16694617v.1 16694617v.1 Updated 02/01/2014 - PAGE 171 - 16694617v.1 16694617v.1 16694617v.1 16694617v.1 / 0 8 9 ? ? ? ? ? ? 1 5 ? ? ? ? ? ? ? J K L ? ? ? ? b c ? ? ? ? ? ? ???????ſſŶ??ſŢ?ŢŒ??ŀ?z?sjŀ?a h?? h?? aJ heGF heGF aJ heGF 5?aJ heGF aJ h?? aJ h?? h?x5 5?>*aJ h?? h?x5 aJ h?? >*aJ h? C >*aJ h?6: 5?aJ h?"? aJ h?"? h?"? aJ h{"Q aJ h? C aJ hC| h? C CJ aJ h? C CJ aJ h? C 5?CJ aJ h\B 5?CJ aJ h?x5 h?x5 h? C 5?>*aJ % / 0 ? ? ? L ? ? 7 A ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?x $If gdeGF $If gdC| & F $1$ If gdC| ?x $If gdC| gd?? % ?x ?x gd?? gd?? gdeGF ?x gd?x5 % ?x ? ? & ? * , . ? g h ? ? ? I J } ~ ? ? $ % H! I! ?! ?! ?! ?! 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10002
12001
MEDSEEK.eHealth.ecoSystemSP.SharePoint, Version=1.0.0.0, Culture=neutral, PublicKeyToken=bc863e8d1af44b20
MEDSEEK.eHealth.ecoSystemSP.SharePoint.EventReceiver.BehaviorMonitoredItemEventReceiver.BehaviorMonitoredItemEventReceiver
Asynchronous
10003
12001
MEDSEEK.eHealth.ecoSystemSP.SharePoint, Version=1.0.0.0, Culture=neutral, PublicKeyToken=bc863e8d1af44b20
MEDSEEK.eHealth.ecoSystemSP.SharePoint.EventReceiver.BehaviorMonitoredItemEventReceiver.BehaviorMonitoredItemEventReceiver
Asynchronous
10001
12001
MEDSEEK.eHealth.ecoSystemSP.SharePoint, Version=1.0.0.0, Culture=neutral, PublicKeyToken=bc863e8d1af44b20
MEDSEEK.eHealth.ecoSystemSP.SharePoint.EventReceiver.BehaviorMonitoredItemEventReceiver.BehaviorMonitoredItemEventReceiver
Document ID Generator
Synchronous
10001
1000
Microsoft.Office.DocumentManagement, Version=14.0.0.0, Culture=neutral, PublicKeyToken=71e9bce111e9429c
Microsoft.Office.DocumentManagement.Internal.DocIdHandler
Document ID Generator
Synchronous
10002
1001
Microsoft.Office.DocumentManagement, Version=14.0.0.0, Culture=neutral, PublicKeyToken=71e9bce111e9429c
Microsoft.Office.DocumentManagement.Internal.DocIdHandler
Document ID Generator
Synchronous
10004
1002
Microsoft.Office.DocumentManagement, Version=14.0.0.0, Culture=neutral, PublicKeyToken=71e9bce111e9429c
Microsoft.Office.DocumentManagement.Internal.DocIdHandler
Document ID Generator
Synchronous
10006
1003
Microsoft.Office.DocumentManagement, Version=14.0.0.0, Culture=neutral, PublicKeyToken=71e9bce111e9429c
Microsoft.Office.DocumentManagement.Internal.DocIdHandler
DocumentLibraryForm
DocumentLibraryForm
DocumentLibraryForm
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