Criminal History & Registry Verification Checks Position applying for(Required) Applicants Name (Print)(Required) SS#(Required)Race / Ethnicity(Required) Date of Birth(Required) MM slash DD slash YYYY Sex(Required) Male Female Other names (aliases, married names, maiden, etc….) I understand that state law requires that Denton Rehabilitation and Nursing Center search my criminal history, State Medicare and Medicaid Exclusion List, the Employee Misconduct Registry* and the DHS Nurse Aide Registry* and must be completed on all applicants before hiring. I authorize Denton Rehabilitation and Nursing Center to conduct this search.Signature(Required) Date(Required) MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
