By the execution of this document, I acknowledge that I have been informed by Once Upon A Time Home Health, LLC that a criminal history check may be performed on my current name, and all past names. Below are all the names I have ever used (i.e. maiden, aliases, nicknames, etc.). Required for criminal checks:

I understand that I may be employed on temporary emergency basis pending the results of the criminal history check. I understand that a person convicted of an offense listed below may not be employed in a position the duties of which involve direct contact with a consumer. I have NOT been convicted of any of the following offenses:

1. An offense under Chapter 19, Penal Code (Criminal Homicide);

2. An offense under Chapter 20, Penal Code (Kidnapping and False imprisonment);

3. An offense under Section21.11, Penal Code (Indecency with a Child);

4. An offense under Section 22.01, Penal Code (Assault);

5. An offense under Section 22.011, Penal Code (Sexual Assault);

6. An offense under Section 22.02, Penal Code (Aggravated Assault);

7. An offense under section 22.041, Penal Code (abandoning or endangering a child);

8. An offense under Section 22.04, Penal Code (injury to a child, Elderly individual, or disabled individual);

9. An offense under Section 22.08, Penal Code (aiding suicide)

10. An offense under Section 25.031, Penal Code (agreement to abduct from custody);

11. An offense under Section 25.08, Penal Code (sale or purchase of a child);

12. An offense under Section 28.02, Penal Code (arson);

13. An offense under Section 29.02, Penal Code (robbery);

14. An offense under Section 29.03, Penal Code (aggravated robbery);

15. An offense under Section 30.02, Penal code (burglary);

16. An offense under Chapter 31, Penal Code (theft);

17. An offense under Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution);

18. An offense under Section 32.46, Penal Code (securing execution of a document by deception)

Once Upon A Time Home Health, LLC Phone: 210-432-6623 Fax: 210-432-2663 onceuponatimehomehealth.com

I have NOT been convicted of any of the following Penal Code offenses, which may potentially bar employment.

We are requesting an employment / personnel reference on the below named person. A complete and prompt response would be appreciated as employment is pending. All information will be held in strict confidence.

hereby authorize the release of any information concerning my previous employment to Once Upon A Time Home Health, LLC.

HUMAN RESOURCES VERIFICATION OF ABOVE INFORMATION (FOR INTERNAL USE ONLY)

I am aware that a consumer report, (motor vehicle record) will be obtained on me in the course of consideration for employment and at any time throughout my employment. An unacceptable driving record could be grounds for non-hire or termination.

I hereby authorize procurement of consumer report(s). If hired (or contracted), this authorization shall remain on file and serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.

acknowledge that a Computerized Criminal History (CCH) check will be performed by accessing the Texas Department of Public Safety Secure Website and will be based on name and DOB identifiers I supply. (This is not a consent form.) Authority for this agency to access an individual’s criminal history data may be found in Texas Government Code 411; Subchapter F. Name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history, therefore the organization conducting the criminal history check is not allowed to discuss with me any criminal history record information obtained using this method. The agency may request that I have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search. Once this process is completed the information on my fingerprint criminal history record may be discussed with me. In order to complete the process I must make an appointment with the Fingerprint Applicant Services of Texas (FAST) as instructed online at www.txdps.state.tx.us /Crime Records/Review of Personal Criminal History or by calling the DPS Program Vendor at 1-888-467-2080, submit a full and complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $24.95 to the fingerprinting services company. (This copy must remain on file by your agency. Required for future DPS Audits)

Please: Check and Initial each Applicable Space