Please answer the following questions as of the current date:

1. Have you ever been convicted of a crime (all felonies and misdemeanors as defined under the NYS Penal Law or the equivalent under Federal Law or the laws of any other state) including, but not limited to, conviction for commission of fraud, embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statement or receiving stolen property?

NO   YES   

2. Are you subject to any pending criminal charges (all felonies and misdemeanors as defined under the NYS Penal Law or the equivalent under Federal Law or the laws of any other state)?

NO   YES

By signing my name below, I attest that the above information is true and complete to the best of my knowledge. I understand that misrepresentations or omissions of fact may affect my consideration for employment.
 
Employee Signature Signature Date   Date   
 
Employee Name