This page contains a PDF, which requires
Adobe Acrobat Reader (opens in new window)
If you are a resident of one of the 50 United States,
please complete the below Disclosure and Authorization Form and click submit.
If you are not a resident of, or have lived outside of, one of the 50 United States,
please print and complete the International Disclosure and Authorization Form (opens in new window), being sure
to sign the form at the bottom. You may submit the form to Palmer in one of three ways:
This notice is to inform you that in preparation for Admission to
Palmer College and future clinical/fieldwork/practicum experiences
we will be obtaining and reviewing a consumer report or an
investigative consumer (Background Check) report on you. This
authorization may be used to obtain a consumer report at any time
during my enrollment at Palmer College.
, hereby consent and
authorize Palmer College or its agent, Inquirehire, to prepare a
consumer report consisting of a search to determine all previous
addresses within the last 7 years, criminal record checks and any other
search necessary to determine suitability for admission and clinical
placement. Our process for obtaining and reviewing a consumer report
will abide by the guidelines of the Fair Credit Reporting Act as related
to the use of consumer reports for employment purposes.
I am providing the following information for the preparation and proper
verification of the consumer report.
Names and Corresponding Years
Please Explain ...
New York students or employees: You have the right to inspect and receive a copy
of any investigative consumer report requested by employer by contacting Inquirehire
at 800-494-5922 or email@example.com.
Permanent Mailing Address
Current Mailing Address (if different than permanent)