Legal Application For Employment Form

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State Zip Code Business Phone Please provide the name and address of your personal or family physician to be contacted in case of an emergency:   Name   Address City State Zip Code  (    )   Business Phone DRUG HISTORY The information contained herein MAY BE a confidential medical record under the Americans with Disabilities Act if the applicant is a rehabilitated drug or alcohol abuser or under section 119.071(4)(b) whether the medical information, if disclosed, would identify the applicant.. Last time illegally experimented with or used: Do you now or have you ever illegally obtained, possessed, supplied, or sold any narcotic or controlled substance such as, but not limited to: cannabinoids, PCP, hallucinogen methaqualone, hashish, cocaine, LSD, amphetamines, heroin, steroid, opiates, barbiturates, benzodiazepine, a snythetic narcotic, a designer drug, or any drug of a similar nature q Yes   q No   If yes, please complete the following: a.. REMARKS (Revised 01/14) Page 15 BACKGROUND INVESTIGATION WAIVER Authority for Release of Information TO: Concerned Person or Authorized Representative of Any Organization, Institution or Repository of Records APPLICANT S NAME: DATE OF BIRTH: SOCIAL SECURITY NO.: EMPLOYING AGENCY REQUESTING BACKGROUND INFO: I hereby authorize any employee or authorized representative bearing this release, or copy thereof, to obtain any information in your files pertaining to my employment records including, but not limited to, achievement, attendance, personal history, disciplinary records, medical records, credit records, and criminal history records.. I hereby release you, as the custodian of such records, and employer, education institution, physician, hospital or other repository of medical records, credit bureau or consumer reporting agency, including its officers, employees, and related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, fam

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