Application

First Home Healthcare, LLC Personal Assistant Services (PAS) Criminal Background Check

Release of Information Authorization Form
By my signature below, I authorize First Home Healthcare, LLC through the State Bureau of Investigation, Division of Criminal Information to perform a Texas criminal history record information check relative to the application for employment and annually as long as I remain an employee with First Home Healthcare, LLC pursuant to Texan Administrative Code, Title 40, Part 1, Chapter 3, § 3.201 Texas Health and Safety Code.
Full Name*

First NameMiddle NameLast Name
Do you have a maiden name or other aliases?*

YesNo
Previous Name (i.e., married name(s) and aliases)

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Have you lived at the above address for less than two (2) years?*

YesNo
Previous Address

Street Address

Street Address Line 2

CityState

Zip Code
Social Security Number*
Date of Birth*

MonthDayYear
Date
Sex*

MaleFemale
Place of Birth*

Street Address

Street Address Line 2

CityState / Province

Postal / ZipCountry
I understand that the Texas Bureau of Investigation, Division of Criminal Information, and its official and employees shall not be held legally accountable in any way for providing this information to the above-named healthcare provider, and I hereby release said Agency and persons from any and all liability which may be incurred as a result of furnishing such information, I further understand that the healthcare provider cannot provide me with a copy of the results of this criminal history record check.
Applicant's Signature*

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Date*

MonthDayYear
Date

DPS Computerized Criminal History (CCH) Verification

(AGENCY COPY)
I, First Name* Last Name* acknowledge that a Computer Criminal History (CCH) check may be performed by accessing the Texas Department of Public Safety Secure Website and may be based on name and DOB identifiers. (This is not a consent form but serves as information for the applicant.) Authority for this agency to access an individual's criminal history data may be found in Texas Government Code 411, Subchapter F.
Name-based information is not an exact search and only fingerprint records searches represent true identification of criminal history record information (CHRI), therefore the organization conducting the criminal history check is not allowed to discuss with any CHRI obtained using the name and DOB method. The agency may request that I also have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search.
In order to complete the fingerprint process I must make an appointment with the Fingerprint Applicant Services of Texas (FAST) as instructed online or at http://www/dps.texas.gov/section/crime-records/crime-records-general-information/Review of Personal Criminal History or by calling the DPS Program Vendor at 1-888-467-2080, submit a full complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $25.00 to the fingerprinting services company.
Once this process is completed the information on my fingerprint criminal history record may be discussed with me.

(This copy must remain on file by this agency. Required for future DPS Audits)
Signature of Applicant or Employee*

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Date*

MonthDayYear
Date
Agency Name (Please print)
Agency Representative Name (Please print)
Signature of Agency Representative
Date

MonthDayYear
Date
Please:

Check and Initial each Applicable Space

CCH Report Printed:

____YES ____NO _____initial

Purpose of CCH:____________________________

Empl ____ Vol/Contractor _____ ______initial

Date Printed: ____________ ______initial

Destroyed Date: ___________ ______initial

Retain in your files
Rev 11/2023

Application For Employment

Education

References

Employment History

Past Employer 1

Past Employer 2

Past Employer 3

First Home Healthcare, LLC Personal Assistant Services (PAS) Criminal Background Check

DPS Computerized Criminal History (CCH) Verification

Payroll Maxx

PAS STAFF TO COMPLETE WITH EMPLOYEE