Criminal History Consent Form at Health Force of Georgia

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.

"*" indicates required fields

Date*

Name*

First Middle Last

Physical Address*

Street Address Address Line 2 / Apt.# City State ZIP Code

Sex*

Female

Male

Race*

American Indian / Alaska Native

Asian

Black / African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Birth Date*

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

Phone

This field is for validation purposes and should be left unchanged.