AUTHORIZED, RELEASE AND ACKNOWLEDGMENT

I hereby authorize any person, entity or institution with which I am currently, or have formerly been associated, including all past and present employers, to release to this hospital, its agents, employees, and representatives, any and all information pertaining to any professional competence, educational background, character, ethical qualifications, and medical history. I further authorize the hospital and its employees, agents and representatives, to contact and consult with any person or institution with which I have been or am currently associated, including past and present employers, who may have such information bearing upon my professional competence, educational background, character, ethical qualifications, and medical history.

I hereby agree to release all individuals and organizations who provide any such information in good faith and without malice from liability or damages on account of having furnished such information.  I hereby agree to release this hospital, its employees, agents and representatives from any liability or damages on account of having obtained any such information while acting in good faith and without malice.

I understand that the accuracy and completeness of the information provided in my application, any supplemental forms, or preemployment interviews, is relied upon by the hospital in making any employment decision.  All information which I have submitted, or which I am asked to later submit, is and will be true, accurate and complete to the best of my knowledge. I understand that any misrepresentation, misstatement, omission, or other attempt to mislead is cause for denial of employment or for dismissal if I am employed prior to discovery.

In connection with my application for employment (including contract for services), I understand that investigative background inquiries are to be made on me which may include consumer credit, criminal convictions, motor vehicle, and other reports.  These reports will include information to my character, work habits, performance, education and experience along with reasons for termination of employment from previous employers. Further, I understand that you may be requesting information from various Federal, State, and other agencies which maintain records concerning my past activities relating to my driving, credit, criminal, civil and other experience as well as claims involving me in the files of insurance companies.

I authorize without reservation, any party or agency contacted to furnish the above mentioned information and release all parties involved from any liability and responsibility for doing so. I hereby consent to obtaining the above information from VeriCORP, Inc. and/or any of their licensed agents. This authorization and consent shall be valid in original, Fax, or copy form. I further authorize ongoing procurement of the above mentioned reports at any time during my employment (or contract) and have received a copy of the Consumer Notification regarding pulling of such consumer reports.

I further agree to notify the hospital of any changes in any employment, training or licensure status, any censure, sanction or disciplinary action by any professional body, or any other information relating to my ability to perform as an employee.

This application will remain active for 90 days.

_____________________________            ______________________________    __________

         Applicants Name                                                  Signature                                   Date

       (Please print or type)

LINCOLN TRAIL BEHAVIORAL

HEALTH SYSTEM

3909 S. WILSON ROAD

RADCLIFF, KY 40160

 CONSUMER REPORTS NOTIFICATION

You are hereby notified that a consumer report or an investigative consumer report may be obtained from a consumer reporting agency, other agency or directly by this employer for the purpose of evaluating you for employment, promotion, reassignment or retention as an employee.

Reports may include consumer credit, criminal convictions, motor vehicle and other reports. These reports may include information as to character, work habits, performance, education and experience along with reasons for termination of employment from previous employers.  Further understand that we may be requesting information from various Federal, State and other agencies which maintain records concerning your past activities relating to your driving, credit, criminal, civil and other experiences.

 (Applicant: Please retain for records)