E-Sign Act Disclosure
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UNMC Allied Health Programs SING

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The fee for the services provided by One Source is $19.26 including Nebraska Sales Tax, payment for which is made directly to One Source and accompanies this request.

You must complete the SING release form and submit to One Source via fax at 800.929.8117. SING Release Form.

The following information may be required by law enforcement agencies, local, state or federal governmental agencies or similar public bodies for positive identification purposes when checking public records. I understand that this information is confidential and will only be used for background screening purposes.

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First NameEnter full LEGAL first name. Do NOT enter nicknames or abbreviations.
Middle NameEnter middle name or initial. Do NOT enter nicknames.
Last NameEnter full legal last name. Do NOT enter nicknames or abbreviations.
SuffixEnter suffix if applicable. EXAMPLE: Jr., Sr., III
AKA First NameEnter full AKA first name. Do NOT enter nicknames or abbreviations.
AKA Middle NameEnter middle name or initial. Do NOT enter nicknames.
AKA Last NameEnter aka or maiden name if applicable.
Street AddressEnter full street address.
Zip Code
Country Code Please change if US is not the correct Country Code.
Request Copy ?For CA, MN, and OK residents, would you like a copy of the report emailed?
SSNEnter social security number. Do not enter hyphens or dashes. EXAMPLE: 111223333
Drivers License NumberEnter Drivers License Number.
Issuing StateEnter Drivers License Issuing State.
Contact Current Employer ?May we contact your current employer?
Phone NumberEnter a phone number the applicant can be reached at between 8 am and 5 pm.
Email AddressEnter an email address. REQUIRED for eSignature on release.
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