* = Required Information

I, , have had no prior convictions of an offense described in the Health and Safety Code which would bar or potentially bar employment as listed below.

  • CRIMINAL HOMICIDE
  • INDECENCY WITH A CHILD
  • SOLICITATION OF A CHILD
  • ARSON
  • AGGRAVATED ROBBERY
  • BURGLARY & CRIMINAL TRESPASS
  • WEAPONS
  • PUBLIC LEWDNESS
  • PUBLIC INDECENCY
  • KIDNAPPING & FALSE IMPRISONMENT
  • AGREEMENT TO ABDUCT FROM CUSTODY
  • SALE OR PURCHASE OF A CHILD
  • ROBBERY
  • ASSAULTIVE OFFENSES
  • THEFT
  • FRAUD
  • INDECENT EXPOSURE
  • A FELONY VIOLATION OF A STATURE INTENDED TO CONTROL THE POSSESSION OR DISTRIBUTION OF AN ILLEGAL SUBSTANCE)

* I UNDERSTAND THAT THE HOME HEALTH AGENCY IS REQUIRED TO CONDUCT A CRIMINAL HISTORY CHECK BEFORE OFFERING ME EMPLOYMENT. I, THE UNDERSIGNING, HEREBY AUTHORIZE THIS AGENCY TO CONDUCT AND VERIFY MY CRIMINAL HISTORY BY PERFORMING A CRIMINAL HISTORY CHECK.


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