CRIMINAL HISTORY SEARCH CONSENT

CRIMINAL HISTORY SEARCH CONSENT FORM






, 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 A SUBSTANCE

(INDIANA CONTROLLED SUBSTANCE ACT)

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