Employee Application Form

Authorization and Consent

I, the undersigned applicant, hereby voluntarily authorize Queenshade LLC, its authorized representatives, and applicable New Jersey state and federal agencies to conduct background checks and employment eligibility screenings as required by the New Jersey Division of Developmental Disabilities (NJ DDD), the New Jersey Department of Human Services (DHS), and applicable laws and regulations.

I understand and agree that these screenings may include:

• Criminal History Background Check: State and federal fingerprint-based Criminal History Record Information (CHRI) checks through the New Jersey State Police, Federal Bureau of Investigation (FBI), and authorized government agencies.
• Central Registry Check: Verification of my status on the New Jersey Central Registry of Offenders Against Individuals with Developmental Disabilities.
• Child Abuse Record Information (CARI) Check: Screening through the New Jersey Department of Children and Families to determine whether my name appears on the applicable child abuse registry.
• Sex Offender Registry Check: Verification against applicable state and federal sex offender registries.
• Exclusion and Debarment Screening: Verification against applicable federal and state healthcare exclusion and debarment databases, including Medicaid and Medicare exclusion lists.
• Ongoing Background Screening: Periodic or additional background checks, including fingerprint archive checks, motor Vehicle checks and registry reviews, as required by NJ DDD, DHS, or other applicable regulatory authorities.

Applicant Acknowledgment

By signing below, I acknowledge and agree that:

• I authorize Queenshade LLC to initiate and coordinate the background checks required for my position.
• I agree to provide accurate identifying information, submit fingerprints when required, and complete all applicable government authorization forms.
• My employment or continued eligibility to provide services is subject to satisfactory completion of all legally required screenings.
• Refusal to complete mandatory background checks may result in withdrawal of an employment offer or other employment action consistent with applicable law.
• Any disqualifying finding will be evaluated and handled according to applicable New Jersey and federal requirements.
• I understand that Queenshade LLC may conduct additional legally required screenings during my employment.
• I authorize the lawful collection, processing, and disclosure of information necessary to complete these screenings, subject to applicable confidentiality and privacy requirements.
• I certify that the information provided in my employment application and related screening documents is true and accurate to the best of my knowledge.

Applicant Consent and Signature