UCHC General Release

General Release Form

United Community Health Center
In connection with my application for employment (including contract for service) with you. I understand that investigative inquiries are to be made on myself including consumer credit, criminal convictions, motor vehicle, and other reports. These reports will include information as to my character, work, habits, performance and experience along with reasons for termination of past employment from previous employers. Further, I understand that you will be requesting information from various Federal, State, and other agencies that maintain records concerning my past activities relating to my driving, credit, criminal, civil, education, and other experiences.

I authorize without reservation any party or agency contacted by this employer to furnish the above-mentioned information.

I hereby consent to your obtaining the above information from Precheck and/or any of their licensed agents. I understand to aid in the proper identific ation of my file or records, the following personal identifiers, as well as other information, is necessary.
Name*

First NameMiddle NameLast Name
Maiden Name (if applicable)
Social Security Number*
Date of Birth*

MonthDayYear
Date
Sex*
Race*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Arizona State Immunization Information System (ASIIS)

Records released will be used for the purposes of tracking occupational health medical information for the purpose of infection prevention and control and to meet regulatory control guidelines.
I understand that, by granting the consent below, I am authorizing release of my immunization records; including but not limited to, lab results, TB skin test, and Chest Xrays, as necessary for verification and infection control purposes information to United Community Health Center.
Applicant Signature*

Clear
Today's Date

MonthDayYear
Date
Prospective Employer:

United Community Health Center

1260 S. Campbell Road, Building 2

Green Valley, AZ 85614

Phone: 520-407-5600

Fax: 520-407-5990
Please enter in the word below*
Should be Empty:

General Release Form

Arizona State Immunization Information System (ASIIS)