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Click ‘Get Form’ to open it in the editor.
Begin by reviewing the policy statement regarding criminal history background checks. Ensure you understand your responsibilities as an employer.
In the section labeled 'Employer Selection of Criminal History Background Check Option', check the box indicating that you have read and understood the policy.
Next, confirm your acceptance of responsibility by checking the second box, acknowledging your awareness of potential consequences when hiring an attendant with a criminal history.
Fill in the details for the attendant you wish to hire, including their name and case ID number in the designated fields.
Provide your own name and case ID number in the respective fields as well.
If applicable, include information for an Authorized Representative (AR) and their case ID number.
Finally, sign and date the form at the bottom to complete your submission.
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