Doea Form 231 - Background Screening - Affidavit Of Good Moral Character (Page 4 of 4) in pdf

STEP THREE:

The employee must complete and sign EITHER (A) OR (B) below.

The Department of Elder Affairs will review the information revealed by the fingerprint screening

and will compare it to the information provided below. It is important to be honest in revealing

any prior criminal history regarding disqualifying offenses listed in this Affidavit. If you have

disqualifying offenses and are otherwise determined eligible to apply for an exemption, the failure

to disclose the offenses in this section may prevent you from being granted an exemption.

(A)

Under penalty of perjury, I ___________________________________________, hereby swear or

affirm that I have no record of disqualifying offenses as listed herein, and I meet the requirements for

qualifying for employment in regards to the background screening standards set forth in Chapter 435

and section 430.0402, F.S. In addition, I agree to immediately inform my employer if arrested or

convicted of any of the disqualifying offenses while employed by my employer.

________________________________________________

_________________________

Employee Signature

Date

(B)

Under penalty of perjury, I __________________________________________, hereby swear or

affirm that I have the following record of disqualifying offenses as listed herein, and I understand that I

may be eligible to file for an exemption from disqualification pursuant to section 435.07, Florida

Statutes. If I am granted an exemption from disqualification, I swear or affirm that I otherwise meet the

requirements for qualifying for employment in regards to the background screening standards set forth

in Chapter 435 and section 430.0402, F.S. In addition, I agree to immediately inform my employer if

arrested or convicted of any of the disqualifying offenses while employed by my employer.

List Disqualifying Offenses:

____________________________________________________________________________________

________________________________________________

_________________________

Employee Signature

Date

DOEA Form 231, Affidavit of Good Moral Character, Effective 8-1-11

Section 435.02(2), F.S.

*Previous versions of this form will not be accepted*

Page 4 of 4

Form available at:

Doea Form 231 - Background Screening - Affidavit Of Good Moral Character Page 4