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.
|
|
|
|
English
Spanish