Fillable Disclosure Statement Application For Employment, Including Provisional Employment Form

DISCLOSURE STATEMENT

APPLICATION FOR EMPLOYMENT, INCLUDING PROVISIONAL EMPLOYMENT

Required by the Child Protective Service Law

23 Pa. C.S. Section 6344 (relating to employees having contact with children; adoptive and foster parents)

I swear/affirm that, if being hired on a provisional basis, I have applied for certification through ChildLine, the

Pennsylvania State Police, and the Federal Bureau of Investigation and am submitting a copy of the appropriate

completed request forms to the employer, administrator, supervisor or other person responsible for employment

decisions.

I swear/affirm that, if providing certifications that have been obtained within the preceding 60 months, I have not

been disqualified from employment as outlined below or have not been convicted of an offense similar in nature

to a crime listed below under the laws or former laws of the United States or one of its territories or possessions,

another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former

law of this Commonwealth.

I swear/affirm that I have not been named as a perpetrator of a founded report of child abuse within the past five

(5) years as defined by the Child Protective Services Law.

I swear/affirm that I have not been convicted of any of the following crimes under Title 18 of the Pennsylvania

consolidated statutes or equivalent crime under the laws or former laws of the United States or one of its

territories or possessions, another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign

nation, or under a former law of this Commonwealth.

Chapter 25

(relating to criminal homicide)

Section 2702

(relating to aggravated assault)

Section 2709.1

(relating to stalking)

Section 2901

(relating to kidnapping)

Section 2902

(relating to unlawful restraint)

Section 3121

(relating to rape)

Section 3122.1

(relating to statutory sexual assault)

Section 3123

(relating to involuntary deviate sexual intercourse)

Section 3124.1

(relating to sexual assault)

Section 3125

(relating to aggravated indecent assault)

Section 3126

(relating to indecent assault)

Section 3127

(relating to indecent exposure)

Section 4302

(relating to incest)

Section 4303

(relating to concealing death of child)

Section 4304

(relating to endangering welfare of children)

Section 4305

(relating to dealing in infant children)

Section 5902(b) (relating to prostitution and related offenses)

Section 5903(c) (d)

(relating to obscene and other sexual material and performances)

Section 6301

(relating to corruption of minors)

Section 6312

(relating to sexual abuse of children), or an equivalent crime under

Federal law or the law of another state.

I swear/affirm that I have not been convicted of a felony offense under Act 64-1972 (relating to the controlled

substance, drug device and cosmetic act) committed within the past five years.

11/3/15

Disclosure Statement Application For Employment, Including Provisional Employment Form - 2015

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