PERMISSION FOR BACKGROUND CHECKS & CAPS UPDATED 10/27/2020

Written Authorization to Request a CAPS Check

Pursuant to §26-3.1-111, C.R.S., certain employers named in the statute are required to request a check of the Colorado Adult Protective Services (APS) data system (CAPS) prior to hiring a new employee who will be providing direct care to at-risk adults. These employers are also authorized by statute, though not required, to request a CAPS check for current employees. The CAPS check will alert the employer as to whether or not a prospective or current employee has been substantiated as a perpetrator of physical abuse, sexual abuse,

caretaker neglect, and/or exploitation of an at-risk adult. More information on the CAPS check requirement can be found in Title 26, Article 3.1 of the Colorado Revised Statutes (C.R.S and 12 CCR 2518-01 of the Colorado Code of Regulations (CCR Written authorization from the applicant/employee using this form is required per APS regulations (12 CCR 2518-1 Please complete this entire form. It is recommended that you and the employer keep a copy of this form for your records.
EMPLOYER INFORMATION
Employer Name *

ANGELS SERVICE LLC
CAPS Check Employer ID # (XXX-##########): *

ANS-0000006024
REQUESTOR INFORMATION
Requestor Name: *

Kirstin Pamboris
Requestor Title: *

Care Coordination Administrator
Requestor Phone Number: *

7202568875
Requestor Phone Extension: *

1
Requestor Email: *

home@watchingfish.com
APPLICANT/EMPLOYEE INFORMATION
Name

First Name Middle Name Last Name
Date of Birth:

Month Day Year
Date
SSN (Last 4 digits):
Maiden Name/Previous Name(s)/Alias(es):
Maiden Name/Previous Name(s)/Alias(es):
DORA License
GENDER:

Woman American Indian/Alaska Native Man Asian Transgender (Identifies as Woman) Black or African American Transgender (Identifies as Man) Hawaiian National & Pacific Islander Unknown Hispanic or Latino Middle Eastern or North African White
RACE/ETHNICITY (Check all that apply):
Home Phone (Including Area Code):
Cell/Mobile Phone (Including Area Code):
Work Phone (Including Area Code):
Work Phone Extension:
Home Email:
example@example.com
Work Email:
example@example.com
Current Address Street:
Address

Current Address City

Street Address Line 2

Current State
Address

Current Address Start Date

Street Address Line 2

Current Zip/Postal Code
All Applicants/Employees are required to have 5 years of residential history provided. If the individual listed above has less than 5 years at their current address, please list the previous addresses for the past 5 years. Use another sheet of paper, if necessary.
Previous Address (street number, street, unit, city, state, zip):
Previous Address (street number, street, unit, city, state, zip):
Address Start and End Dates:

Month Day Year
Date
Previous Address (street number, street, unit, city, state, zip):
Previous Address (street number, street, unit, city, state, zip):
Address Start and End Dates:

Month Day Year
Date
Previous Employer(s) Agency Name(s):
Previous Employer(s) Agency Name(s):
By my signature, below, I attest that all information provided in this written authorization is true and complete. My signature authorizes the employer referenced above to request a CAPS Check to determine if I have been substantiated in an APS case as a perpetrator of physical abuse, sexual abuse, caretaker neglect, and/or exploitation of an at-risk adult. I acknowledge that the information resulting from such a check will be shared directly with the employer who may use the results to inform their hiring decision. By my signature I acknowledge that this request will flag my name to allow notification to this employer of any future substantiated findings as long as I am employed by this agency.
ADDITIONAL BACKGROUND CHECK PERMISSION
Please read and sign this form in the space provided below. Your written authorization is necessary for completion of the application process. The below individual hereby authorizes ANGELS SERVICE LLC to investigate my background and qualifications for purposes of evaluating whether I am qualified for the position for which I am applying. I understand that ANGELS SERVICELLC will utilize an outside firm or firms to assist it in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company's choice. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application for employment OR CONTRACT REQUEST will not be processed further.

I AGREE AND GRANT PERMISSION THAT ANGELS SERVICE LLC WILL RUN BACKGROUND CHECKS PRIOR TO AND THROUGHOUT THE TIME I AM ASSOICATED WITH THEM.
Signature:
Date:

Month Day Year
Date
Should be Empty:

EMPLOYER INFORMATION

REQUESTOR INFORMATION

APPLICANT/EMPLOYEE INFORMATION

ADDITIONAL BACKGROUND CHECK PERMISSION