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ARREST/CONVICTION REPORT AND CERTIFICATION FORM (onder Act 240 2011 and Act $2 of 2012) | ratteninine: Thearote Erich Werldeisec I 6.28, i904 Other sues by a ised of an ffs offenses enumertd under By checking this ox I epor th Ihave been est fr ofthis For forint of Repable Oe. DABS hie1e)eo (C1) eRepeable fens). Se Fo cach ret far or somston of my Reporable Oese specif in the pe blow oon date and lection of arrest andor conviction, dosker number, andthe applicable court a % By checking this box, eta have NOT been named eer fa founded repr of hil ose within the pst ve (3) years dfn by the Child Prete Services Law a By checking this ox repo tt have bec aed pep founded report f il abuse wine ast ve (5) ens define the Child Protective Services i Offs Realores. Worblenee TE _H-10-2019 subject me criminal prosciton under 18 PsCS 804, lating uae fla INSTRUCTIONS, Pursuant to 24 PS. $1-11(64) an), the Pemnylvania Deparment of Edson developed this sind fom {PDE-«004) a be ued curren and prospec eplayess of uc al pve bls nemedite ni,and ‘en voetioalechncl shoal ‘As equied ty subsection) and (x2) of 24 PS. f-11 his orm sal be competed and sb yal ‘arent and prespetve employers of dtr io povde wien rpg any et or conwston Foran ‘ese enumerated oder 24P'.§8-111e) nd) an provide notifcaton of faving been mane a pear of founded eon a ld hase within he pst ve (3) gets defied ty te Cl Prete Serer Law As toque by subsection XA) of 24 PS. 1-11, this fom also sl be lias by suet and prospective “empoyees to provide writen neice wibia seventy two (72) hore aera bese ares Or oton fr a ‘tense caumartes ender 24 PS §61-11(¢) or (3), In accordance with 24 PS. 1-11, employees completing thi frm are equi o sbi the form tothe ‘dour or athe: person esonsle eremploymen dein na School ety. Pane coc ripest ‘orth school ny adiistaton oie with any questions regarding the PDE 600% ican whom fhe orm shoeld be set PROVIDE ALL INFORMATION REQUIRED BY THIS FORM LEGIBLY IN INK. LIST OF REPORTABLE OFFENSES + Areportable offense enumerated under 265. §1-111() const of any ofthe following: (2) Anoffense under one omar ofthe allows provision of Tite Ifo the PeonyaniaConsaied Sante + caper 25 sing to imi homicide) Sexton 4304 (cela endangering 1 Sestion 702 reli to gerne se) stelle fein) Scotian 27081 ling stalking) + Sesion 305 (relat to aig fe Seton 2901 (reine Knap) deo) Seton 2902 (eling to unl esi) + eon ese under seen $9028) 4 Secon 2010 reling faring hil foto tor (elit positon and elated tense) ‘hice ratte) 7 + Section S908) oe (lating to obscene Sewn 3121 lating rape) 4 Sexin 31221 (ling to Satutory Sexual sal) sn other ena mates and 1 Seen 3123 (eligi ovate sea petornances) intercourse) + Sion 301010) Gelatin corption Seton 31241 casing sen asl) gfeinon) Seton 31242 (feaing instal sxul asa) * ‘Seton 6312 lating tsa abuse of 4 Seton 3125(relaing to aggravate indecent ul) chien) Sesion 3126 (elingt indecent sal + Seton 618 elaingo ula const 5 Sct 3127 eng indecent expose) ith in 5 Scton 3129 (eng seta! ineeoune witha) * Seton 6519 lingo slistaon of 5 Soon 4302 (ean ses) rosie 1 Section 303 lating a comeing den ofchidy Sesion 620 lain to sexual me > exoetation of ier) (2) An ofense designated a. flony under the at of Apel 14, 1972 (PL. 233, No, 6, known “Te Cnt Substance, Dr Debice sn Cosmetic A (0) Anfense SIMILAR IN NATURE to thse crimes sd above in clauses (1) an (2) under the laws or former nso + ope ofits tetas or pomeons oF 1 nue state: or + the Dat f Combi oF + the Commonwealth of ae Rico or ‘foreign ation: * ers former ofthis Commnnwcsks “+ Areportable offense enumerated under 24S. §1-111(C1) const of any ofthe followings (0) Anomtense graded as elon fens fhe is, ssond or tid dre, er thn one af he fess enumerated under 24 PS. §1-11(6 ethan (10) en ears ha ped rom the at ‘ot expration of te sentence for he ess (2) Anoffenseyradd sa misdemeanor af the Fist dares oe than one ofthe offenses courted tinier 245. §1-11 1) iless than (3) fe ears haslased rom he deo xprsion ofthe Seotence ore oes (8) An ofenseunder 75 PaCS § 38024) (b(t (eating diving nde inene of ‘cohol or controled sabsance) graded asa mSdemeanr ofthe ft dgre unde 7 PaCS § 53803 (lang 1 grain) he pore has been previous conse f sch ah fence a iss ian (3 ee yeas hs lapsed form the dato expiration ofthe sees fr the mos reset tense