Personal Information

Full Name

Date of Birth

Current Address

City

State

ZIP Code

Phone Number

Email Address

Consent for Background Check

I hereby authorize the designated agency or employer to conduct a background check, which may include criminal history, employment history, and other personal records as necessary for the position of Home Health Aide.

I acknowledge and give my consent for the background check.

Signature

Signature Date

Home Health Aide Background Check Consent Form

Personal Information

Consent for Background Check

Signature