Criminal History Authorization Form

Background Check Submission Consent

All Is Well Home Care is required to conduct a background check on all individuals 18 years of age and older. Any previous acts committed and noted on your record does not automatically disqualify your employment. However, you will be evaluated based on all the information gathered.
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Submission Data: We respect the privacy of our users and the privacy of their client data. All user information contained within the forms you may use or build on the JotForm Site are governed by our Terms of Service. You retain all rights to your data. We will not sell, share data. We will not access your data for non-administrative reasons.
By signing this application, you are agreeing to submit your names for a criminal history, driver screenings, and registry searches.
Name

First NameLast Name
All cities in which you have lived in Texas:
Please write n/a if not applicable.
Out of Texas address (including county) you have resided over the past 5 years:
Please write n/a if not applicable
Please upload a copy of your Driver's License or ID card

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Please upload a copy of your Social Security Card

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Signature*

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Should be Empty:

Background Check Submission Consent