Volunteer Form - Exemption From Fbi Clearance printable pdf download

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Volunteer Form – Exemption from FBI Clearance

Name (Please Print):

Address:

Phone:

Email:

______________________________________________________________________________

I am applying for an unpaid volunteer position with the American Chemical Society – Philadelphia Section (a 501(c)(3)

organization) and the Philadelphia Area Girls Enjoying Science

(PAGES

) program.

I have requested a child abuse background clearance from the Department of Human Services and a criminal background

clearance from the Pennsylvania State Police. I am attaching copies of my request forms here. I understand that I will be required

to produce original clearance reports before beginning service.

In addition, I swear or affirm that I have been a resident of Pennsylvania during the entirety of the previous ten-year period, am

not disqualified from service and have not been convicted of any of the enumerated offenses below or crimes similar in nature to

those enumerated, or the attempt, solicitation, or conspiracy thereof, or equivalent crimes in another state or under federal law, or

a United States territory or possession, the District of Columbia, the Commonwealth of Puerto Rico, or a foreign nation. I

therefore am exempt from having to submit an FBI criminal background clearance form.

Chapter 25 (criminal homicide)

Section 2702 (aggravated assault)

Section 2709.1 (stalking)

Section 2901 (kidnapping)

Section 2902 (unlawful restraint)

Section 2910 (luring a child into a motor vehicle or structure)

Section 3121 (rape)

Section 3122.1 (statutory sexual assault)

Section 3123 (involuntary deviate sexual intercourse)

Section 3124.1 (sexual assault)

Section 3124.2 (institutional sexual assault)

Section 3125 (aggravated indecent assault)

Section 3126 (indecent assault)

Section 3127 (indecent exposure)

Section 4302 (incest)

Section 4303 (concealing death of child)

Section 4304 (endangering welfare of children)

Section 4305 (dealing in infant children)

Section 5902(b) (prostitution and related offenses) Form created February 12, 2015

Section 5903(c) or (d) (obscene and other sexual materials and performances)

Section 6301 (corruption of minors)

Section 6312 (sexual abuse of children)

Section 6318 (unlawful contact with minor)

Section 6319 (solicitation of minors to traffic drugs)

Section 6320 (sexual exploitation of children)

I hereby swear or affirm that the information set forth is true and correct to the best of my knowledge and belief. I understand t

hat,

if information is obtained that I am disqualified from volunteering, I will be dismissed from volunteer status immediately. I also

understand that I am signing this document subject to penalty under Sections 4903 and 4904 of the Pennsylvania Criminal Code

(false swearing and unsworn falsification).

Name: _____________________ Signature: _____________________ Date: _________

Witness: _____________________ Signature: _____________________ Date: _________

Volunteer Form - Exemption From Fbi Clearance

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