Form LIC 508B. Criminal Record Statement - Long-Term Care Ombudsman Program - California

Form LIC 508B is used in California by individuals applying to become part of the Long-Term Care Ombudsman Program to disclose their criminal records. The main purpose of this form is to ensure the safety and well-being of residents in long-term care facilities by assessing the suitability of program participants.

The form consists of sections where the applicant provides personal information, including their name, address, date of birth, and social security number. Additionally, there are sections that require disclosure of any criminal convictions or pending charges. The form may also include spaces for the signature of the applicant and the date of submission.

Important fields on this form include accurately disclosing any criminal history, providing complete and truthful information, and complying with applicable regulations regarding criminal record statements for the Long-Term Care Ombudsman Program. It is crucial for the applicant to be transparent about their criminal background to ensure the trust and confidence of residents in long-term care facilities.

Application Example: An individual is applying to become a volunteer ombudsman in the Long-Term Care Ombudsman Program in California. Form LIC 508B would be completed by the applicant to disclose their criminal record. By submitting the form, the applicant demonstrates honesty and transparency, allowing the program administrators to assess their suitability for working with vulnerable adults in long-term care facilities.

Related Forms: There are no specific related forms mentioned for Form LIC 508B. However, other documentation such as fingerprint clearance forms, background check authorization forms, and references may be required in conjunction with this form to ensure a comprehensive evaluation of the applicant's suitability for the program.