CRIMINAL BACKGROUND QUESTIONNAIRE

Last Name First M.I. SSN:

You DO NOT have to disclose any material sealed, expunged, or set aside under Federal or State law, or juvenile delinquent or youthful offender
adjudications.

Note: A criminal record will not necessarily exclude you from employment. Factors such as age at the time of the offense, rehabilitation efforts,
seriousness of the crime, and date of the conviction will be taken into account as will the relationship between the offenses and particular jobs for
which you have applied.

1. Are criminal charges currently pending against you? YES NO

2. Were you ever convicted of an offense anywhere? YES NO

YES NO
3. Are you currently on probation?

YES NO
4. Are you currently on parole?

Convictions are not an absolute bar to employment. Other factors will effect a final decision.

IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, YOU MUST PROVIDE FULL DETAILS INCLUDING DATES
AND ATTACH DISPOSITION INFORMATION

DISCLAIMER AND SIGNATURE

I declare, under penalties of the penal law, that I have completed the Criminal Information page and that the statements contained therein are to the
best of my knowledge and belief, true and correct and that I have not knowingly and willingly made a false statement or given information which I
know to be false in connection therewith.

Signature Date

Revised 09/11/2017