SWORN STATEMENT FOR APPLICANTS FOR LICENSED HOME CARE ORGANIZATION

Sworn Statement for Applicants of Licensed Home Care Organizations
Address
Address
City
State/Province
Zip/Postal
1. Have you ever been convicted of any crime within Virginia or the United States?
2. Have you ever been the subject of a founded complaint of child or elder abuse or neglect within or outside Virginia?
3. Are you the subject of any pending criminal charges within or outside Virginia?