Criminal Background Check Authorization

  • By my electronic signature below, I authorize At Home Assisted Living Services, LLC. to perform a criminal history record information check relative to my application for employment or volunteer services with At Home Assisted Living Services, LLC. pursuant to IC 16-27-2-5.
  • If applicant has lived at the above address for less than two (2) years, please list previous address(es) below:
  • I understand that the healthcare provider cannot provide me with a copy of the results of this criminal history record check.
 

Driver's License Check Authorization

  • By my electronic signature below, I authorize At Home Assisted Living Services, LLC. to perform a driver's license record information check relative to my application for employment or volunteer services with At Home Assisted Living Services, LLC.
  • I understand that the healthcare provider cannot provide me with a copy of the results of this driving history record check.
 

Verification

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