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

MM slash DD slash YYYY
Physical Address*
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)*
Clicking submit serves as my electronic signature.
I consent to my submitted data being collected and stored*
This field is for validation purposes and should be left unchanged.