Have you ever been convicted of any of the following crimes against children or other persons:
Dependency action to have neglected or sexually assaulted/abused or exploited any minor or adult person or to have physically abused any minor?
Domestic relations proceeding to have sexually abused or exploited any minor or to have physically abused a minor?
Disciplinary board final decision to have neglected or sexually or physically abused or exploited any minor or adult person?
Court or State licensing board action to have neglected or sexually abused or exploited any minor or adult person?
Discip1inary board final decision to have abused or financially exploited any person 60 years or older who has a functional, mental or physical inability to care for himself or who is a patient in a state hospital?
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 himself or herself who is a patient in a state hospital?
Has it been determined by any state agency or department that you have abused, neglected or Exploited anyone?
Has a court issued any order of protection against you for abuse or exploitation?
Have you ever had a license to care for children or adults denied, revoked or suspended?
First, Second or third degree Extortion
First, Second, or Third degree Theft
First or Second degree Robbery
Or any of these crimes as they may have been renamed
UNDER PENALTY OF PERJURY, I certify that the above information is true, correct, and complete. I understand that ifI 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, lntellicorp & other states.
You will be notified of the State Patrol’s & Intellicorp’s responses within ten days after we receive the report. We will make a copy of the report available to you upon your request.