Addendum For Child Care Positions

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ADDENDUM FOR
CHILD CARE POSITIONS
HAVE YOU EVER BEEN ARRESTED FOR OR CHARGED WITH AN OFFENSE INVOLVING
A CHILD, A SEX CRIME, A SUBSTANCE ABUSE FELONY OR A VIOLENT CRIME?
__________________NO
__________________YES
IF “YES”, PLEASE DESCRIBE THE DISPOSITION OF THE ARREST OR CHARGE:
DATA REQUIRED BY THE PRIVACY ACT OF 1974
THE INFORMATION REQUESTED OF YOU ON THIS FORM IS REQUIRED BY SECTION
231(d), PUBLIC LAW 101-647, OMNIBUS CRIME CONTROL ACT OF 1990, FOR
EMPLOYMENT APPLICATIONS FOR POSITIONS INVOLVING CHILD CARE SERVICES.
______________________________________________________________________________
I CERTIFY THAT THE INFORMATION PROVIDED BY ME ON THIS FORM IS TRUE,
COMPLETE, AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
___________________________________
(SIGNATURE AND DATE)
___________________________________
(PRINT NAME)
DA 3433-2 Equivalent

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