Release of Information
This is to certify that, I have grant Home of Love, LLC permission to conduct thorough inquiries into my past employment, educational background, criminal history, tribal affiliations, state and national sex offender databases, professional license records, and any other aspects related to my personal and professional character. I acknowledge that Home of Love, LLC reserves the right to contact additional references pertaining to my suitability for the position. I hereby release from any liability all individuals, companies, and corporations that provide such information. I understand that any falsification, misrepresentation, or significant omission may result in denial of employment or subsequent termination. I acknowledge that a telephonic facsimile (fax) or photographic copy holds the same validity as the original document. This release applies to most federal, state, and county agencies. In case an agency or source requires an alternative release form or additional identifying information to disclose requested details, I commit to providing the necessary data and signing any additional authorization forms as requested by Home of Love, LLC. In alignment with AMPM §1240(c)(8)(a)(iv) and ACOM Policy No. 429, I grant Home of Love, LLC permission to access my Direct Care Worker testing records from the Arizona Health Care Cost Containment Database (https:/dcwrecords.azahcccs.gov/). I am aware that this information will be stored in my Provider file and is subject to regular review, audit, and/or investigation by state, federal, and independent agencies with whom Home of Love, LLC may hold a contractual, regulatory, or oversight relationship. The ensuing details are mandatory for identification purposes when cross-referencing public records with law enforcement agencies and other relevant entities. I acknowledge that this information is confidential and will solely be used for identification purposes. I hereby release the employer, its representatives, officials, and assigned agencies, including individual officers, employees, and related personnel, from any and all liability for potential damages that could arise for me, my heirs, family, or associates as a result of the solicitation or release of the above-mentioned information or report. I affirm the accuracy and truthfulness of the information provided in this form. I acknowledge that providing false information, misrepresentation, or deliberate omission could result in my disqualification from employment consideration. In the event that I am hired or currently employed by the company, such actions may lead to disciplinary measures, including termination. I also recognize that my association with Home of Love, LLC is subject to the validation and confirmation of my documents, references, work history, and other relevant information pertaining to my employment. I acknowledge that both my engagement with Home of Love, LLC and the agency's decision regarding my employment are based on mutual agreement. This release will remain valid for a duration of twelve (12) months from the date below or for the duration of my employment with Home of Love, LLC.
