Disclosure

I have applied for employment with Luminous Healthcare and have provided them with information regarding my previous employment.

I hereby authorise Luminous Healthcare to conduct a reference check with my present/previous employer(s). I understand that the reference information may include verbal and written information about my employment history.

My signature below authorises my present/previous employers and references to release information regarding my employment record with their organisation and to provide any additional information that may be necessary for my application for employment with Luminous Healthcare whether the information is positive or negative.

I voluntarily release present/previous employers, references and Luminous Healthcare from any and all liability arising from their giving or receiving information about my employment history and suitability for employment.

I also give Luminous Healthcare authorisation to obtain feedback and references from my supervisors over the course of my employment.

This form may be photocopied or reproduced, and these copies will be as effective as a release or consent as the original which I sign.

Name (please print)

Signed

Date

Contact Number

Email