Last Name:
First Name:
M.I.
Maiden/Other Names Used:
SS#:
Date of Birth:
Place of Birth:
Citizenship:
Driver’s License #:
Telephone:
Gender:
Race:
Eye Color: Hair Color:
Height:
Weight:
Home Address :
Have you ever been accused, arrested, or convicted for any criminal offense excluding minor traffic violations (if yes, please explain) : Have you ever been accused, arrested, or convicted of abuse or sexually related crimes? (if yes, please explain) :
Please note: answering “yes” to any of these questions does not automatically disqualify you. Please use the spaces provided to explain the circumstances. I hereby authorize All Care Consultants, Inc. to make an independent investigation of my background and criminal or police records. I release All Care Consultants, Inc., and any person or entity which provides information pursuant to this authorization, from any and all liabilities, claims, or law suits in regards to the information obtained from any and all of the above sources. The information contained in this application is complete and correct to the best of my knowledge. I understand that any omission of material fact on this application may be grounds for rejection of this application or may result in my release from employment. I also understand that my offer of employment and continued employment is contingent upon the results of this background check.
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