Background

Applied Home Care's Consent Form For

Georgia Bureau of Investigation Georgia Crime Information Center

I hereby authorize Applied Home Care to receive any criminal history record Georgia criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia.
Name

Middle (Maiden Name or Other)Last Name
First Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
St
Zip
Sex
Race
Wgt.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Place of Birth
Driver's License No.
State
Expires
Social Security
Applicant's Signature
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Special employment provisions (check if applicable):
One of the following must be checked

I (put your name below) give consent to the above named to perform periodic criminal history background checks for the duration of my employment with this company.
Completed by Director/Owner/Designee:

Applied Home Care

3469 Lawrenceville Hwy, Suite 206

Tucker, GA 30084

770-270-2221 info@appliedhomecare.com

My Signature indicates that I am the Director/Owner/Designee and I have verified the above information on the applicant.
Director/Owner/Designee Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Director/Owner/Designee Signature

First NameLast Name
Director/Owner/Designee Name (Please Print)
Should be Empty: