Background Check Form
The Drug Enforcement Administration (DEA) requires that any person who will have access to controlled substances as a result of his or her status as an employee or agent of Blue Springs Animal Hospital & Pet Resort answer the following questions. Any false information or omission of information may jeopardize your position with respect to employment. Information revealed by this questionnaire will not necessarily preclude employment or affect continued employment, but will be considered as part of an overall evaluation of your qualifications and job responsibilities. The responses on this questionnaire will be held in the strictest confidence.
Name
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First Name
Last Name
Email
*
example@example.com
In the past 5 years, have you been convicted of a felony, or within the past two years of any misdemeanor, or are you presently charged with committing a criminal offense? Do not include traffic violations, juvenile offenses or military convictions, except by general court-martial.
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Yes
No
Yes - Felony
Please furnish details about the offense, conviction, and sentence.
What is the approximate date of the conviction?
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Month
-
Day
Year
Date
In what location did the offense occur? (Provide City and State if in the U.S. or City and Country if outside the U.S.)
In the past three years, have you ever knowingly used any narcotics, amphetamines or barbiturates, other than those prescribed to you by a physician?
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Yes
No
Yes - narcotics
Please furnish details
Approximate starting date of drug use
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Month
-
Day
Year
Date
Are you currently using these drugs? If not, please give an approximate date when you stopped using these drugs.
Comments
Please verify that you are human
*
Submit
Should be Empty: