Application for a Napa County Caregiver Permit

* = Required fields

Contact Information & Identification

 First*MILast*
Name:*
Address: Address 2:
City: State:    Zip:  
Email: Primary Phone:*
Cell Phone: Message:
Birth Date:*     Driver's License #:     State:
Height: Height:    Weight:    Hair Color:
Former Name(s)/Aliases:

Licenses

Business License #: Valid Dates: City/County:
Other Licenses
Description/Number Valid Dates
Suspended/Revoked
Suspended/Revoked
Suspended/Revoked

Criminal History

Crime Date Convicted Parole/Probation Dates

Residental Addresses (past 5 years)

Address City, State, Zip Dates

Work & Caregiver History (past 5 years)

1 Dates Job Company
 
  Address Phone
 
   
2 Dates Job Company
 
  Address Phone
 
   
3 Dates Job Company
 
  Address Phone
 
   
4 Dates Job Company
 
  Address Phone
 
   
5 Dates Job Company
 
  Address Phone
 
   
6 Dates Job Company
 
  Address Phone
 
   
7 Dates Job Company
 
  Address Phone
 
   
8 Dates Job Company
 
  Address Phone
 

Please make sure you have provided all relevant information. Incomplete or missing information may result in an unsuccessful background check.

To the full extent permitted by law, I shall hold harmless, defend at my own expense, and indemnify the County of Napa and the Area Agency on Aging Serving Napa and Solano and their officers, agents, employees and volunteers from any and all liability, claims, losses, damages or expenses, including reasonable attorney fees, for personal injury (including death) or damage to property, arising from all acts or omissions of the applicant. I understand that all fees are non-refundable. I also certify, under penalty of perjury under the laws of California, that the information on this page is true and correct.

I Agree   Date: