Chamblee Police Department Criminal History Consent Form I hereby authorize Health Force of Georgia to receive any Georgia criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia. Date* Date Format: MM slash DD slash YYYY Name* First Middle Last Physical Address* Street Address Address Line 2 / Apt.# City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Sex*FemaleMaleRace* American Indian / Alaska Native Asian Black / African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Birth Date* Date Format: MM slash DD slash YYYY Special Employment Provisions - Purpose code “N” - Employment with Eldercare - I hereby give consent to perform periodic criminal history background checks for the duration of my employment with Health Force of Georgia. Name (electronic signature)* First Middle Last Clicking submit serves as my electronic signature.I consent to my submitted data being collected and stored* Yes EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.