Disclosure and Authorization Form

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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:

* Required

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.

I, * , 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

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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 inbox@inquirehire.com.

Permanent Mailing Address

Current Mailing Address (if different than permanent)

Electronic Signature

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