Application Form

• Felony violation of a protective order (§ 1-253.2)
• Murder or manslaughter (§ 2-30 et seq.)
• Malicious wounding by mob (§ 2-41)
• Abduction (subsection A or B of § 2-47)
• Abduction for immoral purposes (§ 2-48)
• Assaults and bodily wounding (§ 2-51 et. seq.)
• Robbery (§ 2-58)
• Carjacking (§ 2-58.1)
• Extortion by threat (§ 2-59)
• Threats of death or bodily injury (§ 2-60)
• Felony stalking (§ 2-60.3)
• Felony violation of a protective order (§ 2-60.4)
• Sexual assault (§ 2-61 et. seq.)
• Arson (§ 2-77 et. seq.)
• Drive by shooting (§ 2-286.1)
• Use of a machine gun in a crime of violence (§ 2-289)
• Aggressive use of a machine gun (§ 2-290)
• Use of a sawed off shotgun in a crime of violence (§ 2-300)

• Pandering (§ 2-355)
• Crimes against nature involving children (§ 2-361)
• Incest (§ 2-366)
• Taking indecent liberties with children (§ 2-370 or § 18.2-370.1)
• Abuse and neglect of children (§ 2-371.1)
• Failure to secure medical attention for an injured child (§ 2-314)
• Obscenity offenses (§ 2-374.1)
• Possession of child pornography (§ 2-374.1:1)
• Electronic facilitation of pornography (§ 2-374.3)
• Abuse and neglect of incapacitated adults (§ 2-369)
• Employing or permitting a minor to assist in an act constituting an offense (§ 2-372 et seq.)
• Delivery of drugs to prisoners (§ 2-474.1)
• Escape from jail (§ 2-477)
• Felonies by prisoners (§ 1-303)

1. 18.2-42. Assault of battery by mob
2. 18.2-46.2. Criminal street gang participation
3. 18.2-46.3. Recruitment for criminal street gang
4. 18.2-46.3:1. Criminal street gang crimes, third or subsequent conviction
5. 18.2-46.3:3. Criminal street gang crimes in gang-free zone
6. 18.2-46.5. Committing, etc., acts of terrorism
7. 18.2-46.6. Possession, etc., of weapon of terrorism or hoax device
8. 18.2-46.7. Act of bioterrorism
9. 18.2-49. Threatening, attempting, or assisting in abduction
10. 18.2-50.3. Enticing another into a dwelling house with intent to commit certain felonies
11. 18.2-60.1. Threatening the Governor or his immediate family
12. 18.2-279. Discharging firearm within or at occupied building or dwelling house
13. 18.2-280. Willfully discharging firearm in public place or on school property
14. 18.2-281. Setting a spring gun or other deadly weapon
15. 18.2-282. Brandishing a firearm on school property
16. 18.2-282.1. Brandishing a machete or other bladed weapon on school property
17. 18.2-287.2. Wearing body armor while committing drug crimes or crimes of violence
18. 18.2-308.4. Possession of firearm while in possession of controlled substances
19. 18.2-346. Solicitation of a minor
20. 18.2-356. Procuring
21. 18.2-357. Receiving money from earnings of prostitute
22. 18.2-357.1. Commercial sex trafficking
23. 18.2-370.2. Sex offenders loitering near school
24. 18.2-370.3. Sex offenders residing near school
25. 18.2-370.4. Sex offenders working at school
26. 2-370.5. Sex offenders on school property
27. 18.2-370.6. Penetration of mouth of child with lascivious intent
28. 18.2-374.4. Display of child pornography or grooming video to a child unlawful
29. 18.2-386.1. Unlawful filming
30. 18.2-386.2. Revenge porn

• 18.2-405. Participating in riot with firearm or weapon
• 18.2-406. Unlawful assembly with firearm or weapon
• 18.2-408. Incitement to riot
• 18.2-413. Failure to disperse riot after declaration of insurrection
• 18.2-414. Injury to person or buildings during riot
• 18.2-423. Cross burning
• 18.2-423.01. Burning object with intent to intimidate
• 18.2-423.1. Display of swastika
• 18.2-423.2. Display of noose
• 18.2-433.2. Paramilitary activity
• 18.2-472.1. Providing false information or failing to register or reregister on the Sex Offender Registry
• 18.2-477.1. Escaping from DJJ facility
• 18.2-477.2. Felonies by juvenile in DJJ facility
• 2-478. Escaping from jail, pre-conviction
• 2-480. Escaping from jail by setting fire
• 18.2-481. Treason
• 2-484. Advocacy of violent revolution
• 18.2-485. Inciting race war
• 37.2-917. Escaping from SVP facility
  
  Convictions that would NOT bar an applicant from employment:
  
  Under state law, convictions for offenses unrelated to abuse or neglect would not disqualify an applicant for employment. Even if the applicant has been convicted of a barrier crime it may not always prevent employment. An applicant who has one misdemeanor conviction specified above may be hired if:
  • (i) The criminal offense did NOT involve abuse or neglect; AND (ii)   Five years have lapsed since the conviction occurred.

• Education/Certification
• Employment
• Residential
• Virginia State Police/Barrier Crime Check
• Arrest and criminal conviction
• Civil lawsuits
• Credit history
• Reference verification
• Motor vehicle report

1. I understand that in connection with my application for employment an investigative report will be obtained. This report or these reports may contain information, but is not limited to, as to my character, general reputation, personal characteristics or mode of living, a criminal background history, verification of current and previous employment, verification of educational credentials, professional reference verification, credit report, motor vehicle report, and the additional matters indicated above and as not prohibited by law.
2. I understand that prior to taking an adverse action based, in whole or in part, on the information contained in any investigative report, a copy of the report will be provided to me. Upon written request, within a reasonable period of time after my receipt of this disclosure, a complete and accurate disclosure of the nature and scope of the investigative reports, which may involve personal interviews with sources such as neighbors, friends and associates, will be made to me. This disclosure shall be made in writing no later than 15 days after the date on which the request for such disclosure was received or such report was first requested, whichever is later.

3.  The information requested will be used in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable federal or state laws. Furthermore; I understand that if I am denied employment because of information contained in whole or in part in investigative reports, I have the right to be notified and given the name and address of the agency or source that provided the information.

4.  I hereby authorize, without any reservation, any party be contacted by FIVE CORNERS HOME HEALTHCARE or its agents, to furnish the information described in Section

5.  I understand that a fax, photographic or electronic copy of this consent and release shall be valid as the original.

6.  I hereby release the agents and employers and all other persons, agencies, and entities providing information or reports about me from any and all liability arising out of the request for or release of any of the above-mentioned information or reports.

7.  I have read and understand this form, and have been given the opportunity to consult with my independent legal advisor. By my signature below, I consent to the release of a information, as defined above, in conjunction with my application for employment and my employment. I understand that my consent will apply throughout my employment, to the extent permitted by law, unless I revoke or cancel my consent by sending a signed letter or statement to the company at any time.

• You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment - or to take another adverse action against you - must tell you, and must give you the name, address, and phone number of the agency that provided the information.
• You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”).  You will be required to provide proper identification, which may include your Social Security number.  In many cases, the disclosure will be free.  You are entitled to a free file disclosure if:
• a person has taken adverse action against you because of information in your credit report;
• you are the victim of identity theft and place a fraud alert in your file;
• your file contains inaccurate information as a result of fraud;
• you are on public assistance;
• you are unemployed but expect to apply for employment within 60 days.

• You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus.  You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it.  In some mortgage transactions, you will receive credit score information for free from the mortgage lender.
• You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous.  See ftc.gov/credit for an explanation of dispute procedures.
• Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days.  However, a consumer reporting agency may continue to report information it has verified as accurate.
• Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

• Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business.  The FCRA specifies those with a valid need for access.
• You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer.  Written consent generally is not required in the trucking industry.  For more information, go to ftc.gov/credit.
• You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on.  You may opt-out with the nationwide credit bureaus at 888-5-OPT-OUT (888-567-8688) or www.optoutprescreen.com.
• You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.
• Identity theft victims and active duty military personnel have additional rights. For more information, visit ftc.gov/credit.