Verification and Authorization Statement

I hereby acknowledge that I have NOT been a resident of the Commonwealth of Pennsylvania for the past two consecutive years.

In accordance with the Older Adults Protective Services Act, I hereby authorize the Commonwealth of Pennsylvania (PA Department of Aging) to conduct a criminal history background check on/for me and to review my criminal history information. I understand that my criminal history record information will not be released to anyone but myself except under court order.

I am aware that I have the right to obtain a copy of the background check report and to challenge its accuracy and completeness. I am also entitled to due process in accordance with applicable statutes.

I do hereby for myself, my heirs, executors, and administrators release and forever discharge the Department of Aging and its agents from any and all claims, actions, or causes of action which may arise as a consequence of the release of my criminal history information.

I understand that the Department of Aging shall provide both me and the facility with a written employment determination letter.

Payment for fingerprinting fees and submission of fingerprints shall be deemed further positive affirmation of my intent to have a fingerprint based criminal history background check performed as authorized above.

  I have read and accepted these terms.