Background Check Authorization
Professional Background Check Authorization template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
Background Check Authorization
TEMPLATE • Inspection-Ready AFH Standard
1. Applicant Personal Identification
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
2. Disclosure & Authorization Consent
FINANCIAL TERMSBase Rate & Payment Schedule: Resident agrees to pay Provider a monthly base fee of $______ payable in advance on the first (1st) day of each calendar month.
3. Section 3: Discharge Protocols & Signatures
Provider Signature / Date
Resident / POA Signature / Date
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Document Section Breakdown (2 Sections)
Applicant Personal Identification
Full legal name, aliases, DOB, SSN, driver license number, and 7-year address history.
Disclosure & Authorization Consent
FCRA disclosure, authorization to run state patrol, FBI, and registry checks.
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