By completing this form the individual certifies the following to be true:

Penal Code Section 11105.03 provides that certain employers may request from the Department of Justice records of all convictions involving certain sex crimes, drug crimes, or crimes of violence of a person who applies for employment or volunteers for a position in which the subject would have a supervisory or disciplinary power over a minor.

Employer, as used in this section, means any nonprofit corporation or other organization, which employs persons or uses the service of volunteers in positions having supervisory or disciplinary power over a child or children.

By submiting this form, the individual certifies that:

1. He or she has not been convicted of any “Sex Crimes” or committed as a mentally disordered sex offender.

2. He or she has not been convicted of any “Drug Crimes”. This means any Felony or Misdemeanor conviction, within 10 years of the date of the employer’s request.

3. He or she has not been convicted of any “Crimes of Violence”. This means any Felony or Misdemeanor convictions, within 10 years of the date of the employer’s request.