ATTESTATION OF GOOD MORAL CHARACTER
To be signed by applicants who have accepted a conditional offer of employment and will begin work on aprovisional basis after preliminary background check is , and pending the outcome of State or Federalfingerprint background results. A copy of this signed attestation must be kept in the conditional hire’s personnelfile.
Name of Provisional Hire (print name):
Has accepted Provisional Employment with (location name):
I hereby attest I am of good moral character and I have not been convicted or found guilty of, or entered a plea of nolo contendere or guilty to, any misdemeanor or felony offense.
I hereby attest I am not disqualified from participation in Medicaid or Medicare programs and have not been sanctioned by any federal or state agency.
I hereby acknowledge my license/certification is in good standing with no pending or prior investigations.
Disclosures (if none state “none”):
This person is personally known to me or produced the following identification, Drivers License, on this October 2, 2023
Witness (type or print name): Charles Williams Title: Administrator
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Good Moral Attestation
Agree & Sign