Background Study Authorization

Background study result must be complete, cleared and in accordance with Minnesota Statue 245C.14 before an employee candidate receives a hire date and allowed to begin working for NEXTCARE LLC. NEXTCARE LLC Human Resource department will notify the potential staff, client (if applicable) and/or the responsible party of an employee’s employment eligibility upon receipt of the background study results.

ONLY COMPLETE BACKGROUND STUDY AUTHORIZATION FORMS CAN BE SUBMITTED. TWO FORMS OF IDENTIFICATION, INCLUDING A VALID PICTURE ID WILL BE NEEDED FOR THE SUBMISSION OF THIS BACKGROUND STUDY.

Please fax a copy of your ID to fax # 612-584-3923
Scan and email to info@nextcaremn.com

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Employee’s Name

First

Last

Birthdate

Gender

Place of Birth (State)

Eye Color

Hair Color

Race

Weight (on picture ID)

Height (on picture ID)

Driver’s License/ State ID Number

U.S. Citizen

Permanent Address

Mailing Address

Employee’s Birthdate (State)

Have you lived outside of Minnesota anytime since 2015. If so, please list other cities/states and months/years lived outside of Minnesota.

Repeater

City/State

Month/Year to Month/Year

Please list all former first and last names

Social Security Number

Phone Number

I authorize NEXTCARE LLC to conduct a background study for the purpose of evaluation my potential employment with their agency. I verify that the above information is correct to the best of my knowledge.

Employee Name

Date

Background Study Authorization

Background Study Authorization

Repeater

Business Hours

Our Location

Direct Contact

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