- 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.