Form - Sworn Statement Virginia - HomeCentris Healthcare

SWORN STATEMENT FOR APPLICANTS FOR LICENSED HOME CARE ORGANIZATION

Sworn Statement for Applicants of Licensed Home Care Organizations

Name

Address

City

State/Province

Zip/Postal

Your Email Address

Your Birth Date: (mm/dd/yyyy)

Regulation

Section 32.1-162.9:1 of the Code of Virginia requires that any applicant for employment with a licensed home care organization provide the Commissioner’s representative with a sworn statement or affirmation disclosing (1) whether the applicant has a criminal conviction or is the subject of any pending criminal charges within or outside The Commonwealth of Virginia, and (2) whether the applicant has been the subject of a founded complaint of child abuse or neglect within or outside the Commonwealth of Virginia.  Such conviction may be relevant if job related but does not bar you from employment. 

Further dissemination of the information provided on this form is prohibited other than to the Commissioner’s representative or a federal or state authority or court as may be required to comply with an express requirement of law for such further dissemination.

1. Have you ever been convicted of any crime within Virginia or the United States?

Yes (in Virginia)

Yes (outside Virginia)

2. Have you ever been the subject of a founded complaint of child or elder abuse or neglect within or outside Virginia?

Yes (in Virginia)

Yes (outside Virginia)

3. Are you the subject of any pending criminal charges within or outside Virginia?

Yes (in Virginia)

Yes (outside Virginia)

If you answered "yes" to any of the questions above, please explain. Otherwise please enter N/A.

Affirmation

I hereby affirm that the information provided on this form is true and complete. I understand that the information is subject to verification.  I understand that any person making a materially false statement on this form shall be guilty of a Class 1 misdemeanor.

Signature

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