APPENDIX D
DISCLOSURE STATEMENT  

Supplement to staff employment application

Full Legal Name  ______________________________________________________________

Other Names Used ______________________________________________________________

Social Security Number __________________________________________________________

Pursuant to the requirements of 1987 Washington Laws Chapter 486, we must ask you to complete the following disclosure statement.  This information will be kept confidential.

 1.   Have you ever been convicted of any of the following crimes against persons(s):

Yes      No                                                                Yes       No 

___      ___      Aggravated murder                               ___      ___    Second-degree statutory rape

___      ___      First-degree murder                              ___      ___    Third-degree statutory rape

___      ___      Second-degree murder                         ___      ___     First-degree robbery

___      ___      First-degree kidnapping                        ___      ___     Second-degree robbery

___      ___      Second-degree kidnapping                   ___      ___     First-degree arson

___      ___      First-degree assault                            ___      ___      First-degree burglary

___      ___      Second-degree assault                        ___      ___     First-degree manslaughter

___      ___      Third-degree assault                            ___      ___     Second-degree manslaughter

___      ___      First-degree rape                                 ___      ___     First-degree extortion

___      ___      Second-degree rape                            ___      ___     Second-degree extortion

___      ___      Third-degree rape                                ___      ___     Indecent liberties

___      ___      First-degree statutory rape                   ___      ___     Incest

___      ___      First-degree promotion prostitution        ___      ___     Simple Assault

___      ___      Communication with a minor                 ___      ___    First-degree criminal
                                                                                                      mistreatment
___      ___      Vehicular homicide                                                                

___      ___      Unlawful imprisonment                          ___      ___   Second-degree criminal
                                                                                                     mistreatment

___      ___      Sexual exploitation of minors               ___      ___  Or any of these crimes as they be
                                                                                                    renamed in the future

If your answer is “yes” to any of the above, please describe and provide the date(s) of the convictions and the sentence(s) imposed.   _______________________________________________________________

  _____________________________________________________________________________________

 _____________________________________________________________________________________

 2.  Have you ever been found to have sexually assaulted or exploited a minor, or to have sexually
 abused a minor in a Dependency Action, a Domestic Relations Proceeding, or Disciplinary
 Board Final Action?

  _____ Yes       _____ No

If your answer is “yes,” please describe and provide the date(s) of the finding(s) and the penalty(s) implied.

___________________________________________________________________________

___________________________________________________________________________

3.   Have you been convicted of any crime in the past seven years?

 If your answer is “yes,” please provide details: ______________________________________________

 _____________________________________________________________________________________

 _____________________________________________________________________________________

We may request your fingerprints to obtain, from the Washington State Patrol criminal identification system, a report of your record of criminal convictions for offenses against persons, civil adjudications of child abuse, and disciplinary board final decisions.  If you are hired before that report is available, YOUR EMPLOYMENT WILL BE CONDITIONED UPON THE RECEIPT OF A SATISFACTORY REPORT.

You will be notified of the State Patrol’s response within 10 days after we receive the report.  We will make a copy of the report available to you upon your request.    
UNDER PENALTY OF PERJURY, I certify that the above information is true, correct and complete.  I understand that if I am hired, I can be discharged for any misrepresentation or omission in the above statement.  I also understand that if I am hired, my employment is conditioned on your receipt of a satisfactory report from the Washington State Patrol.

Applicant Signature _____________________________________________________________

Printed Name __________________________________________________________________

Date Signed ___________________________________________________________________

Witness Signature ______________________________________________________________

Printed Name __________________________________________________________________

Back     Next