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Get MA Attestation for Certificate of Clearance for Renewal 2018-2024

Rate. _______________________________________ Signature of employee Revised July. 2018 PART II. Criminal Background Check Report: Have you completed a criminal background check on this employee in the past 30 days? Yes No, the following information was obtained from a criminal record report received on the following date_____________________ Has the employee disputed the results of the criminal background check? Yes No If you answered “yes” to the previous question, please explain the di.

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