Consent And Disclaimer Form printable pdf download

CONSENT AND DISCLAIMER FORM

(TO BE MAILED BY THE EMPLOYER TO:

The Department of Attorney General

Attn: Deputy Director, Medicaid Fraud &Patient Abuse Unit

150 South Main Street, Providence, RI 02903)

NAME OF JUVENILE APPLICANT: ______________________________________________________

PLEASE PRINT NAME CLEARLY

ALIAS: ___________________________________________ DATE OF BIRTH: ______/ _____/ ______

ADDRESS: ____________________________________________________________________________

NAME AND ADDRESS OF EMPLOYING AGENCY:

____________________________________

Signature of Employer/Supervisor: _________________________________________________________

I, ___________________________________, am the parent/guardian/or attorney of record of the above-

named juvenile, who seeks employment with ________________________________________________.

I hereby authorize and direct The Department of Attorney General to review any file in reference to the

above-named juvenile for record of an offense, which, if committed by an adult, would constitute

disqualifying information pursuant to R.I.G.L. §23-17-37. If no such record is found, The Department of

Attorney General will return this form to the above-mentioned Employing Agency indicating same.

I hereby waive and release any and all manners of action, causes of action, and demands of every kind,

nature and description, arising from this request, whatsoever against the State of Rhode Island and the

employees of The Department of Attorney General in both law and equity which I may now have or in the

future may have.

____________________________________

Signature of Parent/Guardian/Attorney

Notary

(TO BE COMPLETED & NOTARIZED PRIOR TO SUBMISSION)

Subscribed and sworn to before me at _________________, County of ____________, State of

__________________ this ________ day of _____________, 20 ____.

_________________________________

NOTARY PUBLIC

My Commission Expires: ___/ ___/ ___.

___________________________________________

Signature of Juvenile Applicant

Notary

(TO BE COMPLETED & NOTARIZED PRIOR TO SUBMISSION)

Subscribed and sworn to before me at _________________, County of ____________, State of

__________________ this ________ day of _____________, 20 ____.

__________________________________

NOTARY PUBLIC

My Commission Expires: ___/ ___/ ___.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_____

NO RECORD OF AN OFFENSE WHICH IF COMMITTED BY AN ADULT WOULD

CONSTITUTE DISQUALIFYING INFORMATION PURSUANT TO R.I.G.L. §23-17-37.

Date: ___/ ___/ ____

___________________________________________

Department of Attorney General

Consent And Disclaimer Form

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