Application

Background Check Disclosure and Authorization

I hereby authorize Selective Case Management, Inc. (SCM) and its representatives to run a
complete background check including, but not limited to education, references, and criminal
history which may be in any state or local files, including those maintained both public and private
organizations for employment purposes.

I specifically authorize my former employers and their representatives to release information
from my personnel file pertaining to performance and the reason for separation. Selective Case
Management, Inc. shall retain the signed copy of this authorization in its files.

I agree information provided is accurate and true. I execute this release with the full knowledge
and understanding that information obtained will be kept confidential, used only for vocational
purposes.

By providing the digital indication of my signature below, I am aware it will be regarded as equivalent to my handwritten signature. My electronic signature confirms that I have reviewed my application for accuracy and completeness and provides consent for Selective Case Management and/or it’s representative’s to conduct and obtain any/all background information relevant to potential employment.

Type your full name into this field

Date
10/29/2020

CONFIDENTIAL MATERIAL: This document is property of Selective Case Management, Inc. and its representatives.
Unauthorized use of this document and information is strictly prohibited. Selective Case Management, Inc. is an
equal opportunity employer.