Access Care Human Services

FINGERPRINTING APPLICATION INFORMATION
Access Care Human Services
112 West Oak Lane, 3rd Floor
Glenolden PA, 19036
PA Employees
HR will conduct a state police background check through the Pennsylvania State Police. The information below is needed to conduct this check. By completing and electronically submitting and signing this form, you are agreeing to and giving Access Care Human Services consent to conduct this background check. In addition, you will be responsible for having FBI clearance checks conducted providing evidence of these clearances to HR.
Name

First NameMiddle NameLast Name
SSN#:
D.O.B
MM DD YYYY
Place of Birth (City):
State/Country of Birth:
Sex:

MaleFemale
Race:

WhiteBlack/African AmericanAsianAmerican IndianHispanicUnknown
Eye Color:
Hair Color:
Height:
Weight:
Country of Citizenship:
Current Address:
City:
State:
Zip Code:
Phone Number:
E mail:
example@example.com
FULL NAME
hereby authorize Access Care Human Services do a full background checks on my, references, character, past employment, education, credit history, adult criminal or police records, and motor vehicle records including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my Application and/or obtaining other information which may be material to my qualifications for service now and, if applicable, during the tenure of my employment or service with Access Care Human Services. The following is my true and complete legal name and all information is true and correct to the best of my knowledge:
Signature:
Employee Signature
Date:

MonthDayYear
Date
Should be Empty:

FINGERPRINTING APPLICATION INFORMATION

Access Care Human Services

112 West Oak Lane, 3rd Floor

Glenolden PA, 19036

PA Employees

MM DD YYYY

Country of Citizenship:

Phone Number:

Signature: