By execution of this document, I acknowledge that I have been informed by the Agency that a criminal history check will be performed on my name. I have informed that Agency of all names (for example, maiden name, aliases) that I have used in the past. I understand that I have been employed on a provisional basis and that my employment is temporary pending the results of the criminal history check. I also understand that it is the Agency’s not to hire an individual who has been convicted of the offenses enumerated below. I also understand that the Agency will make other searches to determine whether any acts of abuse, neglect or exploitation have occurred and whether my name is designated on either registry. If my name is designated on either registry I understand the Agency will deny me employment.

Drug Delivery Resulting in Death

Involuntary Deviate Sexual Intercourse

Securing Execution of Documents by Deception

Endangering Welfare of a Child

Intimidation of Witnesses or Victims

Retaliation Against Witness or Victim

Obscene or Other Sexual Materials to Minors

Obscene or Other Sexual Materials

Acquisition of Controlled Substance by Fraud

Possession with Intent to Deliver

Illegal Sale of Non-Controlled Substance

Any Other Felony Drug Conviction Appearing On PA Rap Sheet

Unauthorized Use of a Motor Vehicle

Unlawful Possession of Retail or Library Theft Instruments

Theft of Unpublished Dramas or Musicals

I,                                       do hereby confirm that I have not been convicted of any felony or misdemeanor listed in PART I above; that I have not been convicted of any felony listed in PART II or PART III above, and; that I have not been convicted of any two misdemeanors listed in PART III, above. I further confirm that there are no charges currently pending against me with respect to the above charges.