Authorization Forms

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.
First Name *
Middle Name
Last Name *
Maiden Name
Previous Name(s) Including Previous Married Name(s) and Aliases:
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
If applicant has lived at the above address for less than two (2) years, please list previous address(es) below:
Additional Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Additional Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Social Security Number *
Date of Birth *
Sex *
Place of Birth:
City
County
State
Country
I understand that the healthcare provider cannot provide me with a copy of the results of this criminal history record check.
Applicant's Signature *
Date

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.
Driver's License Number *
State Issued *
Expiration Date *
Type *
I understand that the healthcare provider cannot provide me with a copy of the results of this driving history record check.
Applicant's Signature *
Date *