BACKGROUND CHECK - The Village@Erlanger

I have applied for employment in a position at a long-term care facility as defined by KRS 216.535(1), or a nursing pool providing staff to a nursing facility, or assisted-living community, involving direct services to a resident or client. I am requesting that the Kentucky State Police provide the employer with any record of conviction found in the files of the Kentucky centralized criminal history record information system. I know that i have the right to inspect my criminal history record and to request correction of any inaccurate information. If I do not exercise that right, I agree to hold harmless the Kentucky State Police and any Kentucky State Police employee(s) from any claim for damages arising from the dissemination of inaccurate information.

First Name

Middle Name or Initial

Last Name

Maiden Name (If Applicable)

Street Address

City

State

Zip

Sex

Race

Date of Birth

Social Security Number

Phone Number

Email Address

Applicant Signature:

Date

Witness Signature:

Date