OCFS 6005 - Criminal Conviction Statement:

OCFS 6005 - Criminal Conviction Statement:
INSTRUCTIONS:
- ALL applicants for a licensure or registration, staff, volunteers, and household members 18 years of age or older must complete and sign this Criminal Conviction Statement.
Which location are you working at?*
PROGRAM NAME
PROGRAM NAME
FACILITY ID NUMBER
FACILITY ID NUMBER
PERSONS FULL NAME*
DATE OF BIRTH (mm/dd/yyyy)*

MonthDayYear
Date
CERTIFICATION
I HAVEI HAVE NOT
To the best of my knowledge the information provided above is true and accurate. I understand that my failure to truthfully and accurately state whether I have been convicted of a crime may constitute grounds for dismissal or denial of employment, or suspension, limitation or revocation of the license or registration to provide child care at this site.
SIGNATURE*

Clear
Date*

MonthDayYear
Date
Should be Empty:

CERTIFICATION