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VOLUNTEER-Criminal History Disclosure Form This form is to be used for the screening of volunteers. Please respond fully to the questions below. In your responses, please be sure to include motor vehicle traffic misdemeanors, but do not include information regarding: minor traffic violations and parking tickets, youth offender adjudications; any conviction that’s been sealed/expunged; or any criminal charges that were resolved in your favor dismissal). Name: _ Date of Birth: _ Former names/aliases/a.k.a.: Have you ever been convicted of, or pled guilty or no contest (“nolo contender”) to a crime (felony or misdemeanor) in any state or federal court? Yes No. If yes, please provide the following disclosure (attach additional records or pages as needed): Criminal Offense Felony/Misdemeanor Classification Date of Offense Location (City, State) Arresting Agency/Jurisdiction Do you have any criminal charges pending against you? Yes No. If yes, please give specifics: I certify that the above disclosures are true and complete. I understand that misrepresentation or omission of relevant facts may result in a decision not to allow me to volunteer. I hereby authorize investigation of all statements contained in this disclosure and any attached data provided. Applicants Signature: Date: Employer Use Only: Received: By:_ Passed: _ Yes No SIGN