Background Check Questionnaire

Pursuant to Connecticut General Statutes § 20-678, MB Home Care LLC requires that all applicants for employment answer the following questions. Please note that you will be subject to a comprehensive background check in connection with your application for employment, and any false written statements regarding such prior criminal convictions or disciplinary action may subject you to criminal penalties.

1. Have you ever been convicted of any crime involving violence or dishonesty in any state or federal court in any state?

If yes, explain:

2. Have you ever been subject to any decision imposing disciplinary action by a licensing agency in any state, the District of Columbia, a United States possession or territory or a foreign jurisdiction?

If yes, explain:

By signing below, I certify that the information I have provided is true and complete to the best of my knowledge.

Printed Name:



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