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Home
About
Our Vision & Values
Our Mission
Meet our Team
Message from the Administrator
Need Our Services?
Invoice
Services
Long Term Care Services
Services for under 21 y/o
Medicaid Waiver Services
Insurance Accepted
Resources
Community Inclusion
Continue Education
Covid 19
Health Summary
AHCA/APD Level 2 Background Screening Information Please complete the following fields accurately. All information must match your Social Security card and Driver's License. This form is confidential and used solely for the purpose of conducting a Level 2 background screening through AHCA and APD
Personal Information
Name:
*
First Name
Last Name
Middle Name:
Second Last Name:
Date of Birth (MM/DD/YYYY):
*
MM
DD
YYYY
Place of Birth (City, State, Country):
*
Social Security Number:
*
Full Home Address (Street, City, State, ZIP):
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email:
*
Physical Description (As per your ID/Driver’s License)
Height (ft/in):
Weight (lbs):
Eye Color:
Hair Color:
Demographic Information (as required by background screening)
Gender:
Male
Female
Other
Race:
White
Black or African America
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Other:
Thank you!
