Clearinghouse Consent – PRG Florida App

Care Provider Background Screening Clearinghouse

I acknowledge that I have received a copy of the privacy policies from the Florida Department of Law Enforcement and the Federal Bureau of Investigation, which describe the exchange of information where criminal record results will become part of the Care Provider Background Screening Clearinghouse.

I understand and agree that I will read and comply with the guidelines contained in the privacy policies.

Your Information

Full Name(Required)

First Middle Last

Cell Phone(Required)

Use the same phone number on all forms.

Email Address(Required)

Use the same email on all forms.

Employee/Contractor Signature(Required)

Use the box below and sign your name here.