Background Check consent form

As a prospective employee of the Galaxy Home Health, LLC, I understand that it is the Agency’s policy to secure conviction criminal history information as a part of the pre-employment screening process.

I authorize Galaxy Home Health, LLC to use the information below for the sole purpose of obtaining a conviction only Criminal History File search.

Applicant’s Name

Last name(Required)

First name(Required)

Middle

Maiden name or name(s) previously used

Date of Birth(Required)

Race

Sex

Driver’s License Number(Required)

State

Applicant’s Signature(Required)

Date(Required)

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