Background Check Information & Release

Golden Horizons ElderCare Services, Inc.

251 Main St. #201
Old Saybrook, CT 06475

Contact: (860) 388-1788

Please provide all information and read disclosures carefully. Then click submit.












Background Information & Release

NOTICE TO APPLICANTS: The information requested below is for the sole purpose of conducting a background investigation that includes, among other things, a criminal records check. The existence of a prior criminal record will not necessarily make you ineligible for employment. It is our policy to evaluate any adverse information obtained in the background investigation based on a range of factors including, but not limited to, employment history and the time, nature and job-relatedness of the offense. The information on this form, along with the final report, will be held in confidence.
Please check that you have read the above NOTICE TO APPLICANTS.

I give my permission to Golden Horizons Elder Care Services, Inc., to conduct a criminal background check on me.

Please list maiden name, or other names formerly used, and the date it was last used.

If this question doesn't apply to you, please enter "N/A".
Date of Birth
Driver's License Number

Driver's License Expiration
If you do not have a license, ignore the question.
Driver's License State of Issue

Please indicate all previous residences for the last 5 years.

Include street address, city, state, zip code and dates of residence (beginning and ending). If it is the same as your current residence, enter "N/A".
Have you ever been convicted (found guilty) of attempting or committing any crime other than a minor traffic violation in state or federal court in any state?

A conviction record will not necessarily bar individuals from employment. You are not required to reveal records which have been judicially expunged, sealed or eradicated.
If YES, what date, year and state?

Have you ever been subject to any decision imposing disciplinary action by a licensing agency in any state, the District of Columbia, a U.S. possession or territory or a foreign jurisdiction?

If YES, what date, year and where?


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