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Healthcare Compliant- Background Check Authorization Form
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Name of the Company to which you are applying :
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Full Name:
First Name
Last Name
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Denial of Existence of criminal history (As required by public act xx of 2006*)
I am hereby advised by the Company that it is necessary to conditionally employ, independently contract and/ or grant clinical privileges to me employee prior to receiving all of the results of the state and national criminal history background .
(1) I swear under penalty of law that I have not been convicted of a felony or misdemeanor within the applicable time period that makes me ineligible, by law to work for this organization. I have reviewed the attached list of felonies
(2) I am not the subject of an order or disposition under section 16b of Chapter IX of the code of criminal procedure, 1927 PA 175, MCL 769.16(b.) relating to finding of not guilty by reason of insanity.
(3) I have not been the subject of a substantiated finding of neglect, abuse, or misappropriation of property by a state or federal agency pursuit to an investigation arising in a skilled nursing facility and conducted in accordance with 42 USC 1395i
(4) I agree that if the information in the criminal history investigation conducted by this organization does not confirm my statements, my employment, contract or clinical privileges
(5) I understand the conditions set forth in Public Act XX of 2006 that result in my termination and agree that these conditions are in fact good cause for termination.
(6) I am aware that the provision of false information regarding my identity or criminal history is a crime punishable by fines and/ or imprisonment.
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Agreement to notify employer of arraignment or conviction
Pursuant to Public Act XX of 2006, I agree, that as a condition of employment or contract, I will immediately report to the Company any arraignment or conviction of one or more of the criminal offenses listed below:
(1) Felony – Any felony or attempt or conspiracy to commit ANYfelony.
(2) Misdemeanor– Any misdemeanor listed below.
[a] A misdemeanor involving abuse or neglect.
[b] A misdemeanor involving cruelty or torture unless otherwise provided under subdivision
[c] A misdemeanor that involving criminal sexual conduct.
[d] A misdemeanor that involves vulnerable adult abuse under chapter XXA of the Michigan Penal Code, 1931 PA 328, MCL 750.145m to 750.145r.
[e] A misdemeanor involving the use of a firearm or dangerous weapon with the intent to injure, the use of a firearm or dangerous weapon that results in a personal injury, or a misdemeanor involving the use of force or violence or the threat .
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Previous name (If any):
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Alias (If any):
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Email Id:
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Mobile No:
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Present Address:
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Zip Code
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Social Security Number:
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Date of Birth:
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Place of birth (City/State) :
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Country of Citizenship:
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Height:
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Weight:
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Hair Color:
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Physical Gender:
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Nationality/Ethnicity:
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Licensed Occupation (Required if you have ever held a license):
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License Number (Required if you have ever held a license):
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Expiration Date:
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State Issued ID Number (Driver's License or ID) :
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Expiration Date:
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Have you resided in Michigan for the past 12 Months:
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Do you have any felony charges pending against you:
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Have you been convicted of a misdemeanor or felony:
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If yes, please provide place, date and violation details:
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If yes, please provide place, date and violation details:
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Signature:
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Date:
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