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Policy on Sexual Abuse of Minors Certification and Authorization Document

Certification

Name:
Please check each statement and sign the certification.
I hereby certify that I have not been convicted of committing, attempting to commit, or conspiracy to commit, any crime, whether a felony or a misdemeanor, in the areas of juvenile prostitution or pimping, obscenity, child pornography, sexual assault, sexual abuse, child exploitation, the cannabis control act, the controlled substance act, a crime of violence, or any other crime where the victim was under the age of eighteen at the time of the offense.
I hereby certify that I have not been convicted of any crime, whether of any other state, of the United States or against the laws of any other jurisdiction, which would have been punishable as one or more of the above crimes
I hereby certify and agree to notify the diocese if arrested for crimes listed above.
I hereby certify that I understand the Policy on Sexual Abuse of Minors by Church Personnel of the Diocese of Springfield in Illinois and I agree to adhere thereto.
I hereby certify that I understand the diocesan code of conduct as set forth in the Policy on Working With Minors and I agree to adhere thereto.
I hereby certify that I understand that any false statement or certification herein will be grounds for immediate termination from employment or volunteer position.

Criminal History Background Search For Employees and Volunteers of the Parish, Pastoral Center & Other Diocesan Institutions

NOT FOR EMPLOYEES OF THE SCHOOL - School Employees contact your School Principal for information on the fingerprint process to complete the Criminal History Background Check.

Check this box if you HAVE completed the Volunteer Criminal History Application On-line via the Diocese web site and DO NOT complete this form.
Check this box if you HAVE NOT completed the Volunteer Criminal History On-Line Application available on the diocesan website and DO complete this form.

INSTRUCTIONS: Provide the information requested in items 1 thru 9 of this form. All information is required unless otherwise noted.

1. In the boxes below list the Parish, School Agency, Office or Institution for Employment or Volunteer Position and the City where located.
2. Report Current Address:
Street Address:
City:
State:
Zip:
3. Maiden Name
4. Additional Names

5. Additional Addresses: List all addresses of residence for past 7 years outside of your current county of residence. Address, City, State and Zip



*Required field for Employment Positions only. Volunteers do not complete this information.

6. *Social Security Number


7. Date of Birth ex: mm/dd/yyyy

8. If you would like to receive a copy of your search results please indicate the method below.

Send results by email to
Send results by USPS to the above address or to the address below:

9. Digitally sign the document.

This completed form will be sent to the Office of Safe Environment for processing located at 1615 W. Washington, Springfield, IL 62702