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ABUSE REGISTRY AND SEX OFFENDER QUESTIONNAIRE

I hereby give consent for Shalom Community Care, Inc. to conduct a check of reports of abuse, neglect or exploitation on record concerning me as well as the known sex offender list available to the public.  I understand that if I am hired, any falsification and/or omissions that are later discovered will be grounds for immediate dismissal.

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List all names, aliases, etc. you have ever used:
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First

Middle

Last

Maiden

List all residences within the United States for the last seven years:

Street Address

County

City, State, Zip Code

Dates of Residence

Street Address

County

City, State, Zip Code

Dates of Residence

Street Address

County

City, State, Zip Code

Dates of Residence

Signature

Social Security #

Date

Shalom Community Care

2201 Murfreesboro Pike
Suite A-222
Nashville, TN 37217
Phone: +1 615 678-5041
Fax: +1 615 457-1193
[email protected]

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