uKinnect | Background Check Authorization

Application for Certified Nursing Assistant (CNA) – In-Home Care

uKinnect, LLC

Background Check Authorization

Contractor Information:

Full Name: {{fullName}}

Other Names Used: {{otherNames}}

Date of Birth: {{dob}}

SSN: {{ssn}}

Driver’s License & State: {{license}}

Address: {{address}}

Country, State, City: {{cityStateZip}}

Phone: {{phone}}

Email: {{email}}

Authorization and Consent:

I hereby authorize uKinnect, LLC ("Company") or its agents to obtain a background check on me. This may include but is not limited to:

Criminal History
Employment Verification
Education Verification
Motor Vehicle Records
Reference Checks
Professional License Verification

This information will be used solely to evaluate my eligibility as an independent contractor. I understand I may request a full disclosure in writing. I release uKinnect and any providers of information from liability. This authorization is valid during my contract or as long as legally allowed.

Contractor’s Acknowledgment and Signature:

Signature:

Printed Name: {{printedName}}

Date: {{dateNow}}