Form 2985
April 2018-E

An applicant for temporary or permanent employment with a licensed child care facility, licensed child placing agency or
registered child care home whose employment or potential employment with the facility, agency, or home involves direct
interaction with, or the opportunity to interact and associate with, children must execute and submit the following affidavit with the
application for employment:

I swear or affirm under penalty of perjury that I do not now and I have not at any time, either as an adult or as a juvenile:

1. Been convicted of;
2. Pleaded guilty to (whether or not resulting in a conviction);
3. Pleaded nolo contendere or no contest to;
4. Admitted;
5. Had any judgment or order rendered against me (whether by default or otherwise);
6. Entered into any settlement of an action or claim of;
7. Had any license, certification, employment, or volunteer position suspended, revoked, terminated, or adversely affected
   because of;
8. Resigned under threat of termination of employment or volunteerism for;
9. Had a report of child abuse or neglect made and substantiated against me for; or
10. Have any pending criminal charges against me in this or any other jurisdiction for;

Any conduct, matter, or thing (irrespective of formal name thereof) constituting or involving (whether under criminal or
civil law of any jurisdiction):

1. Any felony;
2. Rape or other sexual assault;
3. Physical, sexual, emotional abuse and/or neglect of a minor;
4. Incest;
5. Exploitation, including sexual, of a minor;
6. Sexual misconduct with a minor;
7. Molestation of a child;
8. Lewdness or indecent exposure;
9. Lewd and lascivious behavior;
10. Obscene or pornographic literature, photographs, or videos;
11. Assault, battery, or any violent offense involving a minor;
12. Endangerment of a child;
13. Any misdemeanor or other offense classification involving a minor or to which a minor was a witness;
14. Unfitness as a parent or custodian;
15. Removing children from a state or concealing children in violation of a court order;
16. Restrictions or limitations on contact or visitation with children or minors resulting from a court order protecting a child or
    minor from abuse, neglect, or exploitation; or,
17. Any type of child abduction.

Form 2985
Page /04-2018-E

The failure or refusal of the applicant to sign or provide the affidavit constitutes good cause for refusal to hire the applicant.

{Seal, if any, of notarial officer}