* Last Name:		* First Name:		Middle Initial:
Maiden/Previous Names:
* Home Address:		* City:
* State:		* Zip Code:
* Social Security Number:		* Date of Birth:
Driver's License Number:		Issuing State:

I authorize SAR Enterprises, Inc., d.b.a. an independently owned and operated Home Instead franchise, to make whatever inquiries it may deem necessary in connection with my course of employment. As part of such inquiries, Employer has my permission to contact persons who may have information regarding my suitability for employment and to secure consumer reports (including investigative consumer reports).

I authorize and instruct any person or agency contacted to participate or conduct inquiries at its request, to compile information, and to furnish any information obtained as a result of such inquiries.

I further authorize Employer, in its sole discretion, to furnish copies of this authorization and my application to any person and/or consumer-reporting agency in connection with above purposes.


I consent to drug testing designed to detect the presence of alcohol or the illegal use of drugs.


Information contained in reports obtained by Employer in accordance with above authorization may include information pertaining to your character, general reputation, police record, personal characteristics, and mode of living. You have the right to request that Employer completely and accurately disclose to you the nature and scope of all investigations requested. Such a request must be made in writing within a reasonable period of time after your application for employment is received.

I hereby acknowledge that I have read and understand the above disclosure statement.

* Signature (type name):

* Date: