Affidavit Relating To Residence And Volunteer Qualification printable pdf download

Affidavit Relating to Residence and Volunteer Qualification

I, (Name) _______________________________________________________________, of

(City, State) _________________________________________________ have applied as a

volunteer with (Organization) ________________________________________________.

I understand this Affidavit for the purpose of determining whether I may serve as an unpaid

volunteer.

I, (Name) _________________________________________________swear and affirm I have

resided inside the Commonwealth of Pennsylvania within the entirety of the ten-year period

immediately preceding today’s date.

I, (Name) ________________________________________________ swear and affirm I am

not disqualified from service pursuant to section 6344 (c) or have not been convicted of an

offense similar in nature to those crimes listed in Section 6344 (c) (see 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 the

commonwealth.

I, (Name) __________________________________________________ swear and affirm I

have not been convicted of a felony offense under the Pennsylvania Controlled Substance, Drug,

Device and Cosmetic Act, 35 P.S. Section 780-101 et seq., during the entirety of the five-year

period immediately preceding today’s date.

Pennsylvania Crimes Code, 18 Pa.C.S.A. Section 101 et seq.:

i. Chapter 25 (relating to criminal homicide);

ii. Section 2702 (relating to aggravated assault);

iii. Section 2709.1 (relating to stalking);

iv. Section 2901 (relating to kidnapping);

v. Section 2902 (relating to unlawful restraint);

vi. Section 3121 (relating to rape);

vii. Section 3122.1 (relating to statutory sexual assault);

viii. Section 3123 (relating to involuntary deviate sexual intercourse);

ix. Section 3124.1 (relating to sexual assault);

x. Section 3125 (relating to aggravated indecent assault);

xi. Section 3126 (relating to indecent assault);

xii. Section 3127 (relating to indecent exposure);

xiii. Section 4302 (relating to incest);

xiv. Section 4303 (relating to concealing death of child);

xv. Section 4304 (relating to endangering welfare of children);

xvi. Section 4305 (relating to dealing in infant children);

xvii. A felony offense under section 5902(b) (relating to prostitution and related offenses);

xviii. Section 5903(c) or (d) (relating to obscene and other sexual materials and performances);

xix. Section 6301 (relating to corruption of minors);

xx. Section 6312 (relating to sexual abuse of children); or

xxi. the attempt, solicitation or conspiracy to commit any of the foregoing criminal offenses.

Signature: _____________________________________________________ Date: _____________

State of ________________________________ County of _________________________________

Sworn to and subscribed before me this ___ day of_______________, (year) _______

Notary Public ____________________________________

My Commission Expires:_____________________________

Affidavit Relating To Residence And Volunteer Qualification

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