CHOICES/SMP Team Member Background and Criminal Records Check Consent Form

CHOICES/SMP Team Member Background and Criminal Records Check Consent Form

Please complete all fields as requested. This platform is HIPAA compliant and secure. Only your regional coordinator will receive and review your submission.
Legal Name

First NameMiddle NameLast NameSuffix
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number. Enter your cell phone number if you do not have a home phone.
Please enter a valid phone number.Format: (000) 000-0000.
Agency on Aging that you partner with
Date of Birth

MonthDayYear
Date
Social Security Number
Driver's license number
If you have a driver's license, you must complete this field.
Driver's license number
If you have a driver's license, you must complete this field.
Issuing state of driver's license
If you have a driver's license, you must complete this field.
Other names you may be known as (maiden name, etc.)
Have you been convicted of a criminal offense within the past seven years, or areyou currently under a warrant or charged with any criminal offense?
If “yes”, please briefly give details below on the nature, location, and date of the offense. Failure to fully and accurately answer this question may lead to immediate dismissal of your application.
I hereby give my consent to the SMP/CHOICES Program and the Area Agency on Aging (AAA) to perform a comprehensive background check as required for the Team Member position for which I have applied. This check will include a criminal records check and may also include reference checks. It may also include checks on my driver’s license, driving record, employment history, and/or volunteer history. I understand that I do not have to agree to this background check, but that my refusal may exclude me from consideration for this position. I understand that the SMP/CHOICES program and the AAA will limit the information it collects to that needed to determine my suitability for particular types of SMP/CHOICES work. I also understand that the confidentiality of information collected during applicant screening is carefully protected and it may be shared with SMP/CHOICES screening/hiring authorities as needed in the determination of applicant suitability. The SMP/CHOICES program will not automatically eliminate from consideration anyone with a criminal record, but some offenses may preclude service in some roles.
Program (select both if you are applying for/active in both programs)
Should be Empty: