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Get Background Clearance Form - Hssu

RE WORKER ($10.00) PERSONAL CARE WORKER($10.00) VOLUNTARY REGISTRANT ($10.00) ELDER CARE WORKER ($10.00) RECIPIENT OF STATE OR FEDERAL FUNDS ($10.00) FOSTER PARENT (NO FEE) SECTION B: IDENTIFYING DATA FOR BACKGROUND SCREENING LAST NAME FIRST NAME MIDDLE NAME MAIDEN NAME PRIOR NAMES USED SOCIAL SECURITY NUMBER (ATTACH COPY OF SOCIAL SECURITY CARD) DATE OF BIRTH GENDER TELEPHONE NO. (optional) MALE FEMALE ( ) MAILING ADDRESS STREET ADDRESS OR POST OFFICE BOX CITY STATE ZIP CO.

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