PRE-CAREGIVING BACKGROUND CHECK AUTHORIZATION

PRE-CAREGIVING BACKGROUND CHECK AUTHORIZATION FORM
I enter your name* understand that as part of the caregiving services process, The Agency needs to complete a background check on me regarding:
1. Criminal record;
2. Sex and Violent Offenders Record;
3. Caregiving services Verification;
4. Education Verification;
5. License Verification;
6. Motor Vehicle Records;
7. Personal/Professional Reference
Verification;
8. Medical Suitability
9. Drugs/Alcohol
Please Read and Check Each Box:*
Signature:*

Clear
Signature Date:*

MonthDayYear
Date
Full Name:
Telephone No:
Former Name(s) and Date(s) Used:

MonthDayYear
Date
Current Address:
Date of Birth:

MonthDayYear
Date
Social Security Number:
Current Driver's License Number:
Issuing State/Country:
List any other cities, states, Countries inlcuding dates of residency for the last 10 years. Please list the most current information first:
#01:*
#02:*
#03:*
#04:
#05:
Should be Empty:

PRE-CAREGIVING BACKGROUND CHECK AUTHORIZATION FORM