CONSENT & DISCLOSURE
Kohll’s Rx Pharmacy & Homecare appreciates your interest in joining this organization. Employment at Kohll’s Rx requires dedication, trust, and honesty. As part of the application and hiring process, we will request an investigative report about you, which may include a background investigation, consistent with applicable federal and state laws, which include obtaining information on convictions and/or pending prosecutions as well as any information contained in the Department of Motor Vehicles records, and other factors that may be relevant to your qualifications to work at our company.
By signing this form, you are doing the following, so please read carefully:
- Authorizing Kohll’s Rx Pharmacy & Homecare to contact law enforcement and other government agencies, and other persons or agencies which may have information about you. You further authorize such agencies and parties to issue applicable reports and provide information to Kohll’s Rx Pharmacy & Homecare.
- Authorizing Kohll’s Rx Pharmacy & Homecare to investigate all the statements and matters in your application and any other information provided by you during the application process or other qualifications to work at Kohll’s Rx Pharmacy & Homecare.
- Authorizing Kohll’s Rx Pharmacy & Homecare to use and show information you have provided on your application to other persons in order to conduct an investigation and to verify the truthfulness and completeness of the information you have provided; and
You understand that you have the right to request, in writing, within a reasonable period of time after today’s date, that if an investigative consumer report is requested by Kohll's Rx Pharmacy & Homecare concerning you, that you be furnished a complete and accurate disclosure of the nature and scope of the information requested and a written summary of your rights prepared as prescribed by law. If such a request is made, Kohll’s Rx Pharmacy & Homecare will mail or otherwise deliver such disclosure and such summary in written form to you not later than five days after the request was received from you or the date the investigative consumer report was first requested by Kohll’s Rx Pharmacy & Homecare, whichever is later.
You also agree to cooperate in any investigation, including a drug test. You agree to release Kohll’s Rx Pharmacy & Homecare, including all officers, agents, and representatives, from any and all liability and damages arising out of any background inquiry concerning you.
You hereby consent to this investigation and authorize Kohll’s Rx Pharmacy & Homecare to procure a consumer report and/or an investigative consumer report on your background.
Please Note: You are NOT creating a "contract of employment" with Kohll’s Rx Pharmacy & Homecare by signing this form. If hired, both you and Kohll’s Rx Pharmacy & Homecare have the right to end your employment at any time for any reason.
You agree that:
- You have read this form carefully and understand it.
- Your signature below indicates your voluntary agreement to the above
THE FOLLOWING INFORMATION IS REQUESTED SOLEY FOR PURPOSES OF CONDUCTING A BACKGROUND INVESTIGATION.
After reading the above statements:
- Print your name, Social Security Number, Birth Month and Day, and address on the lines below.
- Sign this form and return it to Kohll’s Rx Pharmacy & Homecare Personnel Office.
BACKGROUND INVESTIGATION WILL BE COMPLETED AT TIME OF HIRE.
The existence of a criminal record will not automatically disqualify you from employment.