Gateway Pediatric Therapy
Notification and Authorization to Release Criminal
Information for Employment Purposes
The position for which I am being considered requires me to consent to a criminal background
check as a condition of employment. This check includes the following: Criminal history
reference searches for felony and misdemeanor convictions at the county and federal levels of
every jurisdiction where I currently reside or where I have resided during the past 7 years; and
sex offender registry searches at the county and federal levels in every jurisdiction where I
currently reside or where I have resided.
I hereby authorize Gateway Pediatric Therapy to conduct the criminal background check
described above. In connection with this, I also authorize the use of law enforcement agencies
and/or private background check organizations to assist Gateway Pediatric Therapy in collecting
this information. ADP has been secured as a third party vendor (consumer reporting agency) to
assist Gateway Pediatric Therapy in collecting and verifying information.
I also am aware that records of arrests on pending charges and/or convictions are not an absolute
bar to employment. Such information will be used to determine whether the results of the
background check reasonably bear on my trustworthiness or my ability to perform the duties of
my position in a manner which is safe for Gateway Pediatric Therapy clients, employees, and
other community members.
Position(s) Applied for:
Please print (for identification purposes):
Full Legal Name:
First Middle Last
Other Names You Have Used in Past Seven Years:
Current Address:
Previous Address (most recent):
Addresses in the 7 years prior to completing this authorization:
Phone Number: Alternate Phone Number:
Gateway Pediatric Therapy
Date of Birth: Gender: Female Male
Social Security Number:
Driver’s License # State of Driver’s License
Have you ever been convicted of a criminal *offense or have any pending criminal* charges
against you?
*This refers only to felonies and misdemeanors; you do not need to include non-criminal traffic
violations or municipal ordinance violations.
Yes (provide detail on next page) No
To the best of my knowledge, the information provided in this Notice and Authorization and any
attachments thereto is true and complete. I understand that any falsification or omission of
information may disqualify me for this position and/or may serve as grounds for the severance of
my employment with Gateway Pediatric Therapy. By signing below I hereby provide my
authorization to Gateway Pediatric Therapy to conduct a criminal background check and I
acknowledge that I have been provided with a summary of my rights under the Fair Credit
Reporting Act which is attached. In addition to those rights, I understand that I have a right to
appeal an adverse employment decision made by Gateway Pediatric Therapy based on my
background check information within three business days of receipt of such notice and that a
determination on my appeal will be made in seven working days from Gateway Pediatric
Therapy's receipt of such appeal.
Signature Date