* = Required Information

I , understand that as part of the employment process, Angel Heart Home Care, LLC , LLC needs to complete a background check on me regarding:

1. Criminal record;
2. Sex and Violent Offenders Record;
3. Employment Verification;
4. Education Verification;
5. License Verification;

6. Motor Vehicle Records;
7. Personal/Professional Reference Verification;
8. Medical Suitability
9. Drugs/Alcohol

• I authorize all federal and state agencies, persons and organizations that may have information relevant to this research to disclose such information to Angel Heart Home Care, LLC or its authorized agent(s).
• I understand that this authorization is to be part of the written and signed employment application.
• I also understand that I do not have to give authorization for a background check but if I don’t give permission, my employment application will not be processed further
• I understand that I have specific rights under the federal Fair Credit Reporting Act (FCRA) and may have additional rights under relevant State law.
• I further authorize that a photocopy of this authorization may be considered as valid as the original.
• I hereby certify that all statements on this form are true and correct to the best of my knowledge and belief. I understand that employment with (Angel Heart Home Care, LLC is contingent upon successful completion of a background check.

List any other cities, states and dates of residency during last 10 years

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