Form Dhcs 3007 Personal Background History Statement
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4State of California – Health and Human Services Agency
Department of Health Care Services
Name of Applicant: _______________________________
Facility No: __________________
PERSONAL BACKGROUND HISTORY STATEMENT
State law requires that persons associated with any DHCS licensed facilities be fingerprinted and disclose any
conviction(s) (Welfare and Institutions Code § 5405.) A conviction is any plea or verdict of guilty or a conviction
following a plea of nolo contendere.
FACILITY INFORMATION
Please select the facility type you are applying for:
MENTAL HEALTH REHABILITATION CENTER
PSYCHIATRIC HEALTH FACILITY
FACILITY NAME: _______________________________________________________________________________
FACILITY NUMBER: ____________________________________________________________________________
POSITION APPLYING FOR: ______________________________________________________________________
PART I: CRIMINAL RECORD STATEMENT
1. Have you ever been convicted of a crime?
Yes
No
You need not disclose any marijuana-related conviction(s) covered by the marijuana reform legislation codified
at Health and Safety Code section 11361.5 and 11361.7.
a. If you answer “yes” to question 1, please describe the nature and circumstances of each crime, location,
and dates of conviction and incarceration. (Use additional sheets of paper, if needed.)
2. If you have ever been convicted of any crime, have you complied with all terms of:
a. Parole
Yes
No
b. Probation
Yes
No
c. Restitution
Yes
No
d. Any other sanction
Yes
No
Please explain any “no” answer given above. (Use additional sheets of paper, if needed.)
3. If you have ever been convicted of any crime, please explain or attach any evidence of rehabilitation. (Use
additional sheets of paper, if needed.)
DHCS 3007 (02/15)
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