JIREH COUNSELING AND CONSULTING SERVICE

CANDIDATE BACKGROUND CHECK ACKNOWLEDGEMENT

STAFF INFORMATION
Applicant

Position

Program Wrap Around IFI Core

Rehire Yes No

JCCS Required To Provide Training Yes No

NEW CHILD & ADOLESCENT EMPLOYEES

All new employees must provide a Criminal Records check in order to work in the Child and Adolescent
Programs.

This documentation must be returned to the Human Resources/Contracts Management Office by

___________________

SIGNATURES

Signature Print Name

Date

Witness
Signature Print Name

Date Copies to Personnel File

BF 804-Candidate Background Check Acknowledgement Est. Mar 2008