- Blue Springs Animal Hospital

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1. In the past 5 years, have you been convicted of a felony, or within the past two years of any misdemeanor, or are you presently charged with committing a criminal offense?*

Do not include traffic violations, juvenile offenses or military convictions, except by general court-martial.

Yes
No

Please furnish details of offense, conviction, and sentence.*

What is the approximate date of the conviction?*

In what location did the offense occur? (Provide City and State if in the U.S. or City and Country if outside the U.S.)*

2. In the past three years, have you ever knowingly used any narcotics, amphetamines or barbiturates, other than those prescribed to you by a physician?*

Yes
No

Please furnish details:*

Approximate Starting Date of Drug Use:*

Are you currently using these drugs? If not, please give an approximate date when you stopped using these drugs.*

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Background Check Form

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