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NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Community Environmental Health and Food Protection Prospective Children's Camp Director Certified Statement THIS STATEMENT IS RELATIVE TO CONVICTION OF A CRIME OR THE EXISTENCE OF A PENDING CRIMINAL ACTION. Have you ever been convicted of a crime a misdemeanor or a felony) or do you presently have a criminal action pending against you? If YES, for each such conviction or pending action provide the following information: 1. The date of the incident which resulted in the criminal conviction or charge: 2. The date of the conviction or charge: 3. The crime you were convicted of or are presently charged with: 4. The nature of the incident which resulted in the criminal conviction or charge: 5. The city, county and state you were convicted in or are presently charged in: 6. The name of the court you were convicted in or are presently charged in: 7. The penalties imposed as a result of the conviction fine, jail term, restitution, etc.): 8. For each of the penalties imposed, list the date the penalty was complied with date fine or restitution was paid in full, date jail term was completed, etc.): Name (children's camp director) I Print Name , certify under penalty of perjury that the above information is complete and accurate. Address Date of Birth STREET CITY CITY COUNTY STATE Date(s) Jail Term Completed STATE ZIP Yr Day Mo Yr Day Mo Yr Day Mo Yr Day Mo Yr Day Mo Yr Day Mo Date(s) 0f Fine Restitution Paid in Full Signature of Children's Camp Director Yr Day Mo Yr Day Mo Yes Yes No YES NO No DOH-2271 (3/06)