8-j. Certified Cleared Employee List.pdf
PDF 239 KB Posted
- Attached to
- Gasoline
- Solicitation number
- IFB No. 26-09 Gasoline
- Issued by
- Rock Island County, Illinois
About this file
The document is a Certified Cleared Employee List form from Rockford Public School District No. 205, designed to verify the criminal background status of employees working with the school district. The form requires vendors, suppliers, professional services firms, or contractors to certify that they have conducted comprehensive background checks on their employees, including criminal history records, Statewide Sex Offender Database checks, and Statewide Child Murderer and Violent Offender Against Youth Database checks, in accordance with Illinois state law (105 ILCS 5/10-21.9).
The form mandates that the vendor certify that none of their employees have been convicted of enumerated criminal or drug offenses listed in the Act and that their names do not appear on the specified databases. The document provides a table for listing employees, with columns for number, last name, middle initial, first name, criminal history, and database checks. The form must be signed by an authorized representative, such as an owner, officer, member, or partner, and then notarized to attest to the accuracy of the information provided.
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Text version
ROCKFORD PUBLIC SCHOOL DISTRICT NO. 205
CERTIFIED CLEARED EMPLOYEE LIST*
The undersigned , a vendor, supplier, professional services firm or contractor, hereby certifies under oath as follows:
1- a criminal history records check, a Statewide Sex Offender Database check and a Statewide Child Murderer and
Violent Offender Against Youth Database check has been conducted for all employees as indicated by a check mark in the appropriate box in accordance with 105 ILCS 5/10-21.9 (the Act); and
2- that such employees have not been convicted of any of the enumerated criminal or drug offenses listed in the Act and their name does not appear on the noted Databases; and
3-the undersigned is an owner (if sole proprietor) or officer, member or partner of the undersigned authorized to execute this document binding the undersigned.
NO. LAST NAME M.I. FIRST NAME
CRIMINAL
HISTORY DATABASES
By:
This certificate Subscribed and Sworn to before me this __ day of ________________, 20__.
Notary Public
Commission Expires: ___________ Vendor Cert. Employee List No._________
* □ check if not applicable. See Supplemental Terms and Conditions section 36.
File details come from the government source that posted it. Updated .