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Concerning your criminal conviction or confirmation of abuse were there things about the commission of the crime or abuse that would demonstrate that it is unlikely to occur again Explain DHS 1200 Rev. 10/15 5. State of Hawaii DEPARTMENT OF HUMAN SERVICES Med-QUEST Division REQUEST FOR EXEMPTION from Criminal History Record and Background Check Standards Section I Individual Seeking Exemption Print Name Last First M. I. Signature Social Security No* Birth Date Home Address Mailing Address Home Telephone Business Telephone Section II Reasons for Exemption COMPLETE ALL OF THE FOLLOWING ITEMS* Use additional sheets of paper if necessary. 1. Identify the agency and/or client that you will serve as a direct service provider or serve in direct contact 2. Describe the type of service you would be providing for the agency and/or client 3. Why do you believe an exemption should be given for your criminal conviction or confirmation of abuse Explain 4. List all significant activities/dates since ....

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Related content

DHS 1200 (Rev. 06/16) Page 1 of 2 State of Hawaii...
DHS 1200 (Rev. 06/16). Page 1 of 2. State of Hawaii. Med-QUEST Division. DEPARTMENT OF...
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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232