Volunteer Request For Waiver Of Fbi '- Federal Criminal History Fingerprint Record Check Form - Commonwealth Of Pennsylvania
ADVERTISEMENT
1VOLUNTEER REQUEST FOR WAIVER OF
FBI – FEDERAL CRIMINAL HISTORY FINGERPRINT RECORD CHECK
(If you qualify for this waiver, this form must be completed and turned into the School office when
submitting the other two PA clearances)
I declare under penalty of perjury that the following is true and correct:
1. I have been a resident of the Commonwealth of Pennsylvania during the entirety of the
previous ten-year period from the date of this document;
2. I have NEVER been named the perpetrator of a founded report of child abuse;
3. I have NEVER been convicted of one or more of the following types of offenses, including the
attempt, solicitation or conspiracy to commit any of the following offenses:
a. Criminal homicide
k.
Indecent exposure
b. Aggravated assault
l.
Incest
c. Stalking
m. Concealing the death of a child
d. Kidnapping
n.
Endangering the welfare of a child
e. Unlawful restraint
o.
Dealing in infant children
f.
Rape
p.
Prostitution and related offenses
g. Statutory sexual assault
q.
Crimes related to obscene and other sexual
h. Sexual assault
materials and performances
i.
Involuntary deviate sexual intercourse
r.
Corruption of minors
j.
Indecent assault
s.
Sexual abuse of children
4. Within a 5-year period immediately preceding the date of this document, I have not been
convicted of a felony offense under The Controlled Substance, Drug, Device and Cosmetic Act;
and
5. I have not been convicted of an offense similar in nature to those crimes listed under paragraphs
2, 3 or 4 above 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 Pennsylvania law.
I understand that statements herein are made subject to the penalties of 18 PA C.S. 4904 relating
to unsworn falsification to authorities.
____________________________________________
_________________________
Signature
Date
____________________________________________
Printed Name
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal