Pharmacy background check

NOTIFICATION & AUTHORIZATION TO CONDUCT BACKGROUND INVESTIGATION

I hereby authorize PRS Pharmacy Services, or its agents, to investigate my background to determine any and all information of concern to my record. I also release employers and persons named in my application from all liability for any damages on account of his/her furnishing said information.

Additionally, I hereby authorize PRS Pharmacy Services to make any investigation of my personal history, educational background, driving record, military record and criminal record through an investigative or credit agency. I authorize the release of this information by the appropriate agencies to the investigating service.

This authorization, in original or copy form, shall be valid for this and for any future reports and updates that may be requested.
Applicant Name


 Social Security #

(i.e. 123-45-6789)		 Date of Birth

(i.e. 01/01/2010)
Other Names Used During Education/Career
 Current Address
 Line 2
City


 State


 Zipcode
RPh License # and State (Please list all current and inactive using the format separated by semi-colon <LicenseNumber>(State)
Example - RP432123L (PA)



Driver's License #


 State


 Expiration Date

(i.e. 01/01/2010)
Addresses for the Past 7 years: (if different from above address)
 (2) Address
 Line 2
City


 State


 Zipcode
 (3) Address
 Line 2
City


 State


 Zipcode
 (4) Address
 Line 2
City


 State


 Zipcode
 (5) Address
 Line 2
City


 State


 Zipcode
Applicant Signature (Initials)
 Date
By entering your initials, you are authorizing PRS Pharmacy Services to proceed with the background investigation and are subject to the same terms as if you were signing this document in person.