Criminal Record Check Administrative Appeal Request

Georgia Department of Community Health
Healthcare Facility Regulation Division (HFRD)

This form is to be completed by the individual petitioner of the appeal or their legal representative.

Please provide the requested information to appeal an Unsatisfactory GCHEXS Determination.

GCHEXS Background Check # (required)

Your employer can provide your Background Check #

First Name (required)

Last Name (required)

Date of Birth (required)

Email Address (required)

Phone Number (required)

Ext.

Alternate Phone Number

Mailing Address (required)

Address Line 2

City/Town (required)

State/Province (required)

ZIP/Postal Code (required)

Date of Unsatisfactory Letter (required)

Do you have an attorney representing you for this appeal?

Yes

Attorney's First Name

Attorney's Last Name

Attorney's Suffix

Your Attorney's Email Address

Your Attorney's Phone Number

Ext:

Your Attorney's Mailing Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Reason for requesting an appeal (required)

Please list all disqualifying offense(s) you are appealing. The offense(s) are listed on the applicant unsatisfactory letter. If you do not have a copy of the letter, please email [email protected].

Offenses (required)

Re-order	Offense	Date	Weight	Operations
	Offense	Date	Item weight

more items

Upload a copy of your documentation. (required)

Upload a copy of your certified arrest/court documentation or a signed and notarized statement from the petitioner which includes the following:

Describe the facts and circumstances around the arrest.
Was anyone harmed in the commission of the crime?
What was your sentence? When were you released from jail and/or probation/parole?

One file only.
256 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

By checking this box, I verify that all information is correct.

Verify Information is Correct

By checking this box, I verify that all information is correct

Signature (required)

Sign above

Date of Signature (required)

Criminal Record Check Administrative Appeal Request

Georgia Department of Community Health
Healthcare Facility Regulation Division (HFRD)

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Georgia Department of Community Health Healthcare Facility Regulation Division (HFRD)

Georgia Department of Community Health
Healthcare Facility Regulation Division (HFRD)