Criminal History Check Page 2
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2Texas Department of Aging
Form 2022
and Disability Services
Page 2 / 06-2011-E
Home and Community Support Services Agencies Licensure
Criminal History Check – Addendum
Owner Name (Last, First, Middle)
Other Names Used (Include married or maiden names, aliases, etc.)
Administrator Name (Last, First, Middle)
Other Names Used (Include married or maiden names, aliases, etc.)
Alternate Administrator Name (Last, First, Middle)
Other Names Used (Include married or maiden names, aliases, etc.)
Chief Financial Officer Name (Last, First, Middle)
Other Names Used (Include married or maiden names, aliases, etc.)
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Parent category: Legal