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A conviction record will not necessarily bar individuals from registration and referral. You are not required to reveal records which have been judicially expunged, sealed or eradicated

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APPLICANT WAIVER

I hereby certify that the information hereunder is correct to the best of my knowledge and understand that falsification of this information is grounds for refusal to process my registration application or provide me with client referrals.

I hereby authorize any of the persons or organizations listed in my application to give all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application, and release all such parties from all liability that may result from furnishing such information to you.

I authorize you to request and receive such information. In consideration for my registraton and my being considered for client referrals by your company, I agree to adhere to the rules and regulations of the AHCA and hereby acknowledge that these rules and regulations may be changed by at any time, without any prior notice.