* = Required Information

Employee Statement Criminal Release Form

I have read the section on criminal history checks and understand the purpose and procedures as stated. I agree to participate in the procedures and grant my permission for the results to be disclosed to the employer, Trinity Services. I understand the criminal history and Health Care Registry check will be completed as a condition of employment.

Trinity Services agree to use the information from the state criminal history check only to verify information on my application for employment or statements I have made in regard to my employment. Trinity Services further agrees that this information will not be released without my written permission unless Trinity Services are authorized by law to release this information. A decision of employment will be made in accordance with Trinity Services criminal policy and the information received from the state’s criminal history check in accordance with the Freedom of Information Act.

I hereby release my employer, its directors, officers, employees, agents, and contractors from all liability claims and damages whatsoever that I may have for administration of the state’s criminal history and Health Care Registry check.

I understand that investigative backgrounds inquires are to be made on me including consumer credit, criminal convictions, motor vehicle, and any other needed reports included for this company. I understand that the company will be requesting information from various state, federal, other agencies and other levels concerning my past activities relating to my driving, credit, criminal, and other experiences as well as claims involving me and insurance companies.

In conclusion, I have read the attachments that define good moral character and testify that I am of good moral character as required by the administrative rules (Public Act 116 of 1973, as amended and Public Act 218 of 1979, as amended). I have not been convicted of nor have any charges pending against me in the areas stated on the attachments. I understand this is a condition of my employment with Trinity Services.

I hereby consent and authorize Trinity Services to obtain any needed information to complete my personnel file. The information can be received in its original state, fax, or copied form.

Trinity Services
Criminal background checks will be conducted on applicants to determine whether any information exists that indicated that the applicant has been convicted of or pleaded guilty to any of the following violations:

Aggravated Murder
Promoting Prostitution
Voluntary Manslaughter
Procuring Prostitution
Involuntary Manslaughter
Felonious Assault
Pandering Obscenity
Illegal use of a Minor
Aggravated Robbery
Patient Abuse
Unlawful Abortion
Endangering Children
Child Stealing
Domestic Violence
Criminal Child Enticement
Sexual Battery
Carrying a concealed Weapon
Sexual Imposition
Trafficking Drugs
Corrupting another with drugs
Adulterated food
Public Indecency
Felonious Sexual penetration
Gross sexual imposition
Compelling Prostitution
Disseminating matter harmful to a juvenile
Pandering Obscenity involving a minor
Failing to provide for a functionally impaired person
Offenses against residences or parties of care facilities
Contributing to the delinquency of children
Having weapons while under disability
Improperly discharging a firearm at or into a school/house

Applicants will not be employed if any information from the above list exists for the applicant. Applicants will also be denied employment if the applicant has committed or pleaded guilty to any of the listed offenses, any other major offenses not listed, or if the applicant refuses to submit fingerprints for a criminal background check.

This form will become part of your Personnel File.

Please initial after reading:

Federal Regulations (45 CFR 92.35) prohibits the purchasing of goods or services with federal money from vendors or employing persons who have been suspended or debarred by the federal government.
The OIG Exclusions List must be searched prior to acceptance of any application or executive of contact. File the completed for in the applicant’s file or with an executed contract. The OIG List can be searched online at www.hhs.gov


Full-time Part-time Temporary Permanent
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Background History

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
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Random Drug Testing will be conducted.
Yes No
Yes No

If yes, please provide:

Yes No

If yes, please provide:

Professional License

Yes No
Yes No
Yes No

Skills, Experience, and Trainings


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5 6 7 8
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1 2 3 4
1 2 3 4

High Schools

Yes No


Yes No

Graduate or Professional

Yes No

Work History

Yes No
Yes No
Yes No


References: Please provide the name, address, and telephone number of three references. (No relatives please)


Certification of Application

I hereby certify that all statements made in this application are true. I understand that any misstatement, misrepresentation, or omission of fact may be cause for my application not to be considered; or if I have been employed, may be cause for my immediate dismissal. I expressly authorize this agency to contact and obtain information from all references, employees, licensing authorities, public agencies, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application or job interview. I hereby waive any rights and claims I may have regarding this agency for seeking, gathering, and using such information process and all other persons, corporations, or organizations for furnishing such information about me. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration.

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