Disclosure-Statement-Form

Disclosure Statement
Area / Base you will be working with: *
Supervisor / Staffing Manager email*
who should receive this document?

Disclosure Statement

Due to issues of liability and as required by State Law (RCW 43.43), we need to ask the following questions. A "Yes" answer will not necessarily disqualify you from consideration for the position for which you have applied. This information will be kept confidential.

Have you ever been convicted of any of the following crimes against children or other persons?*

	Yes	No
Aggrevated Murder
1st or 2nd degree murder
1st or 2nd degree kidnapping
1st or 2nd degree assault
1st or 2nd degree rape
1st or 2nd degree rape of a child
1st or 2nd degree robbery
1st or 2nd degree manslaughter
1st or 2nd degree extortion
1st or 2nd degree criminal mistreatment
Child abuse or neglect as defined in RCW 26.44.020
Malicious harassment
1st or 2nd or 3rd degree child molestation
Custodial assault
Promoting pornography
Or any of these crimes as they have been renamed
1st degree promoting prostitution
Communication with a minor
1st degree arson
1st degree bulglary
Indecent liberties
Incest
Vehicular homicide
Unlawful imprisonment
Simple assault
Sexual exploitation of minors
1st or 2nd degree custodial interference
Prostitution
Selling or distributing erotic material to a minor
1st or 2nd or 3rd degree sexual misconduct with a minor
Child buying or selling
Patronizing a juvenile prostitute
Violation of child abuse restraining order

If your answer is " YES " to any of the above, please describe and provide the date(s) of the conviction(s) and the sentence(s) imposed upon you.

Have you ever been convicted of any of the following crimes related to financial exploitation of a person 60 years of age or older, who has a functional, mental or physical inability to care for him/herself or is a patient in a State hospital:*

	Yes	No
1st, 2nd, or 3rd degree extortion
1st, 2nd, or 3rd degree robbery
1st, 2nd, or 3rd degree theft
Forgery
Or any of these crimes as they have been renamed

If your answer is "YES" to any of the above, please describe and provide the date(s) of the conviction(s) and the sentence(s) imposed upon you.
Have you ever been found in any dependency* action to have sexually assaulted or exploited any minor or to have physically abused any minor?*

YesNo
Have you ever been found in a court in a domestic relations proceeding (divorce, dissolution or custody action) to have physically abused or exploited any minor?*

YesNo
Have you ever been found in any disciplinary board final decision to have sexually or physically abused or exploited any minor or developmentally disabled person?*

YesNo
Have you ever been found in any disciplinary board final decision to have abused or financially exploited any persons 60 years or age or older who has a functional, mental or physical inability to care for him/herself or who is a patient in a state hospital?*

YesNo
Have you ever been found by a court in a protection proceeding under Chapter 74.34 RCW to have abused or financially exploited a person 60 years of age or older who has a functional, mental or physical inability to care for him/herself or who is a patient in a state hospital?*

YesNo
If your answer is "YES" to any of questions 1-5 above please describe and provide the date(s) of the finding(s) and the penalty(ies) imposed:
UNDER PENALTY OF PERJURY, I certify that the above information is true, correct and complete. I understand that if I am hired, I can be discharged for any misrepresentation or omission in the above statement. I also understand that if I am hired, my employment is conditioned on your receipt of a satisfactory report from the Washington State Patrol.
Signature*

Clear
Name (print)*
Drivers License No.
Date*

MonthDayYear
Date
We may request your fingerprints to obtain from the Washington State Patrol criminal identification system a report of your record of criminal convictions for offenses against persons, civil adjudications of child abuse, and disciplinary board final decisions. If you are hired before that report is available, YOUR EMPLOYMENT WILL BE CONDITIONED UPON THE RECEIPT OF A SATISFACTORY REPORT.

You will be notified of the State Patrol's response within 10 days after we receive the report. We will make a copy of the report available to you upon your request.
Should be Empty:

Disclosure Statement

Disclosure Statement