Colonial Heights Rehabilitation And Healthcare Center
831 E Ellerslie Ave,
Colonial Heights, VA 23834

Phone: 804-526-6851
colonialheightshc.com

CRIMINAL HISTORY RECORD/SEX OFFENDER AND CRIMES AGAINST MINORS REGISTRY SEARCH FORM

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Virginia State Police

CCRE — Attention: New Form

Mail Request To: P.O. Box 85076

Richmond, Virginia 23261-5076

PURPOSE OF THIS REQUEST (Check only one):
Race:
Sex :
Date of Birth:
Social Security Number:

I certify I am entitled by law to receive the requested record and that the record provided shall be used only for the screening of the current or prospective employees. I understand that further dissemination of Criminal History Records or their use for purposes not authorized by law is prohibited and constitutes a violation punishable as a class 1 or class 2 misdemeanor. If I am an employer or prospective employer,I have obtained the written consent on whom the data is being obtained, and have personally been presented the same person’s valid photo-identification.

Date of Request:
Signature of Person Making Request:
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Printed Name
NAME AND MAILING ADDRESS OF AGENCY, INDIVIDUAL OR AUTHORIZED AGENT MAKING REQUEST:
FEES FOR SERVICE:
FEES $20.00 COMBINATION CRIMINAL HISTORY & SEX OFFENDER SEARCH
* FEES For Volunteers with Non-Profit Org:

* To be entitled to reduced price, services must be on volunteer basis for a non-profit organization with a tax exempt number. Attach documentation to form which supports volunteering status and include organization's name, address, and your tax exempt ‘identification number.

METHOD OF PAYMENT:: (Note: Personal Checks Not Accepted)
CHARGE CARD
Signature of Cardholder:
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FOR STATE POLICE USE ONLY -— DO NOT WRITE BELOW THIS LINE

Response based on comparison of name information submitted in request apainst a master name index maintained in the Central Criminal Records Exchange only.

Purpose code

Disclosure and Release

The company that has provided you this form and asked you to execute this continuing authorization (Employer) may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a "consumer report" and/or an investigative consumer report" which may Include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your criminal history, education, employment history and/or drug testing conducted through Accutrace, Inc. P.O. Box 624, Bryn Mawr, PA 19010 or by contacting us at 1-888-54-TRACE or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing Employer to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment is limited to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

New York applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by Employer by contacting the consumer reporting agency identified above directly.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of 'consumer reports" and/or Investigative consumer reports" at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Accutrace, Inc. or another outside organization acting on behalf of Employer, and/or Employer itself. I agree that a facsimile (lax") or photographic copy of this Authorization shall be as valid as the original.

Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Employer.
Catifomia applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report if one Is obtained by the Employer at no charge whenever you have a right to receive such a copy under California law.

Signature
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Previous Addresses within the Past 7 Years (Use back ff additional space is needed)

SWORN STATEMENT OR AFFIRMATION

Please Print
1. Have you ever been convicted of or are you the subject of pending charges of any crime within the Commonwealth or equivalent offense outside the Commonwealth?


If yes or pending, specify crime(s):


If yes or pending, specify crime(s) and state, or other location:
2. Have you ever been the subject of a founded complaint of child abuse or neglect within or outside the Commonwealth?

If yes or pending, specify state or other location:
I hereby affirm that the information provided on this form is true and complete. I understand that the information is subject to verification.
Signature
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Virginia Addendum to Application for Employment

Have you ever been convicted of a misdemeanor or felony?

(You may answer "No" as to any criminal charge which has been expunged.)
If "Yes," please explain.
A criminal conviction will not necessarily disqualify you from employment. Factors such as the nature and gravity of the offense, the time that has passed since the conviction and/or completion of the sentence, and the nature of the job for which you are being considered, will be taken into account.
Signature
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Printed Name