CSO-1229A.pdf

CSO-1229A (1-16)

Previous versions not accepted

ARIZONA DEPARTMENT OF CHILD SAFETY

CRIMINAL HISTORY SELF DISCLOSURE AFFIDAVIT

Your fingerprints will be submitted to the Arizona Department of Public Safety (DPS) and the Federal Bureau of Investigation (FBI) for a criminal history check. Your self-disclosure on this affidavit and the information provided by your criminal history check will be used, as authorized by Public Law and Arizona Revised Statues, to help us determine your fitness to have unsupervised access to vulnerable persons.

Your failure to disclose true and accurate information on this affidavit will be sufficient grounds to end your employment or to deny, suspend, or revoke your license and may be referred to the State Attorney General’s Office for prosecution.

Be sure that you go over all five (5) pages of the self-disclosure affidavit.

You have the right to obtain a copy of any background check report and challenge the accuracy or completeness of information contained in the report. If you challenge the information, you also have a right to prompt determination as to the validity of your challenge. To obtain a copy of your background check report, contact the DPS Records Unit, ACJIS Division at (602) 223-2222.

YOUR NAME (First, Middle, Last) DATE OF BIRTH (MM/DD/YY)

ADDRESS (No., Street, Apt. No., City, State, ZIP)

Check one of the following and provide information as directed:

I have not been arrested for, convicted of, nor am I under pending indictment for any crimes.

I have been arrested for, convicted of, or I am under pending indictment for the following crime(s) (Provide dates, location/jurisdiction, circumstances and outcome. Attach additional pages as needed):

ALSO – Check one of the following:

I am not subject to registration as a sex offender in Arizona or in any other jurisdiction.

I am subject to registration as a sex offender in Arizona or in any other jurisdiction. (If you are subject to registration as a sex offender in this state or any other jurisdiction, DPS will deny you a Level 1 Fingerprint Clearance Card and you WILL NOT be eligible to appeal the decision.)

I certify that I understand this affidavit. My self-disclosure is true, accurate, and complete to the best of my knowledge.

Your Signature Date

Notary Public

State of Arizona, County of

Subscribed and sworn or affirmed and acknowledged before me this day of , 20

Commission Expiration date Notary Public’s Signature

CSO-1229A (1-16) - Page 2

Non-Appealable Offenses Are you awaiting trial for or have you ever been convicted of committing, attempting to commit, soliciting or facilitating or conspiring to commit one or more of these crimes in this state or a similar crime in another jurisdiction? Mark “Yes” or “No” as applicable.

If you are subject to registration as a sex offender in this state or any other jurisdiction, or awaiting trial on or been convicted of committing, attempting to commit, soliciting or facilitating, or conspiring to commit one or more of the crimes in this section DPS will deny you a Level 1 Fingerprint Clearance Card and you WILL NOT be eligible to appeal the decision.

Expunged convictions from any court other than juvenile court must be identified.

YES NO

1. Sexual abuse of vulnerable adult

2. Incest

3. Homicide, including first or second-degree murder, manslaughter and negligent homicide

4. Sexual assault

5. Sexual exploitation of a minor or vulnerable adult

6. Commercial sexual exploitation of a minor or vulnerable adult

7. Child prostitution as prescribed in A.R.S. § 13-3212

8. Child abuse

9. Felony child neglect

10. Sexual conduct with a minor

11. Molestation of a child or vulnerable adult

12. Dangerous crime against children as defined in A.R.S. § 13-705

13. Exploitation of minors involving drug offenses

14. Taking a child for the purposes of prostitution as defined in A.R.S. § 13-3206

15. Neglect or abuse of a vulnerable adult

16. Sex trafficking

17. Sexual abuse

18. Production, publication, sale, possession and presentation of obscene items as prescribed in A.R.S. § 13-3506

19. Furnishing harmful items to minors as prescribed in A.R.S. § 13-3506

20. Furnishing harmful items to minors by internet activity as prescribed in A.R.S. § 13-3506.01

21. Obscene or indecent telephone communications to minors for commercial purposes as prescribed in

A.R.S. § 13-3512

22. Luring a minor for sexual exploitation

23. Enticement of persons for purposes of prostitution

24. Procurement by false pretenses of persons for purposes of prostitution

25. Procuring or placing persons in a house of prostitution

26. Receiving earnings of a prostitute

27. Causing one’s spouse to become a prostitute

28. Detention of persons in a house of prostitution for debt

29. Keeping or residing in a house of prostitution or employment in prostitution

30. Pandering

31. Trafficking of persons for forced labor or services as defined in A.R.S. § 13-1308

32. Transporting persons for the purpose of prostitution, polygamy and concubinage

33. Portraying adult as a minor as prescribed in A.R.S. § 13-3555

34. Admitting minors to public displays of sexual conduct as prescribed in A.R.S. § 13-3558

35. Any felony offense involving contributing to the delinquency of a minor

36. Unlawful sale or purchase of children

37. Child bigamy

38. Any felony offense involving domestic violence as defined in A.R.S. § 13-3601, except for a felony offense only involving criminal damage in an amount more than $250, but less than $1000 if the offense was committed before June 29, 2009.

39. Felony indecent exposure

40. Felony public sexual indecency

41. Felony driving under the influence, driving under the extreme influence or aggravated driving under the influence if committed within 5 years of the date you apply for a Level 1 Clearance Card.

42. Terrorism

43. Any offense involving a violent crime as defined in A.R.S. § 13-901.03

CSO-1229A (1-16) - Page 3

Appealable 5 Years After Conviction The following felony offenses are non-appealable if committed within 5 years before the date you apply for a Level 1 Fingerprint Clearance Card. If you have been convicted of committing, attempting to commit, soliciting or facilitating or conspiring to commit one or more of the crimes in this section within 5 years of applying for a Level 1 Fingerprint Clearance Card, DPS will deny you a Level 1 Fingerprint Clearance Card and you WILL NOT be eligible to appeal the denial.

If the conviction was more than 5 years before you apply for a Level 1 Fingerprint Clearance Card, DPS will deny you a Level 1 Fingerprint Clearance Card, but you will be eligible to appeal the denial to the Arizona Board of Fingerprinting.

Mark “Within 5 Years,” “Over 5 Years” or “No” as applicable.

WITHIN

5 YEARS

OVER 5

YEARS NO

1. Endangerment

2. Threatening or intimidating

3. Assault

4. Aggravated assault

5. Unlawfully administrating intoxicating liquors, narcotic drugs or dangerous drugs

6. Dangerous or deadly assault by prisoner or juvenile

7. Prisoners who commit assault with intent to incite to riot or participate in riot

8. Assault by vicious animals

9. Drive by shooting

10. Assaults on public safety employees or volunteers and state hospital employees

11. Discharging a firearm at a structure

12. Prisoner assault with bodily fluids

13. Aiming a laser pointer at a peace officer

14. Possession and sale of peyote

15. Possession and sale of a vapor-releasing substance containing a toxic substance

16. Selling or giving nitrous oxide to underage persons

17. Sale of regulated chemicals

18. Sale of precursor chemicals

19. Production or transportation of marijuana

20. Possession, use or sale of marijuana, dangerous drugs or narcotic drugs

21. Possession, use, administration, acquisition, sale, manufacture or transportation of prescription-only drugs

22. Administration, acquisition, manufacture or transportation of dangerous drugs or narcotic drugs

23. Manufacturing methamphetamine under circumstances that cause physical injury to a minor under the age of 15

24. Involving or using minors in drug offenses

25. Possession, use, sale or transfer of marijuana, peyote, prescription drugs, dangerous drugs, or narcotic drugs or manufacture of dangerous drugs in a drug-free school zone

26. Possession, manufacture, delivery and advertisement of drug paraphernalia

27. Use of wire communication or electronic communication in drug-related transactions

28. Using a building for sale or manufacture of dangerous or narcotic drugs

29. Manufacture or distribution of prescription-only drug

30. Manufacture, distribution, possession, or possession with intent to use imitation controlled substances, imitation prescription-only drugs or imitation over-the-counter drugs

31. Manufacture of certain substances and drugs by certain means

CSO-1229A (1-16) - Page 4

Appealable Offenses Are you awaiting trial for or have you ever been convicted of committing, attempting to commit, soliciting or facilitating or conspiring to commit one or more of these crimes in this state or a similar crime in another jurisdiction? Mark “Yes” or “No” as applicable.

If you are awaiting trial on or been convicted of committing, attempting to commit, soliciting or facilitating or conspiring to commit one or more of these crimes, DPS will deny you a Level 1 Fingerprint Clearance Card, but you will be eligible to appeal the decision to the Arizona Board of Fingerprinting.

YES NO

1. Theft

2. Theft by extortion

3. Shoplifting

4. Forgery

5. Criminal possession of a forgery device

6. Obtaining a signature by deception

7. Criminal impersonation

8. Theft of a credit card or obtaining a credit card by fraudulent means

9. Receipt of anything of value obtained by fraudulent use of a credit card

10. Forgery of a credit card

11. Fraudulent use of a credit card

12. Possession of any machinery, plate or other contrivance or incomplete credit card

13. False statements as to financial condition or identity to obtain a credit card

14. Fraud by persons authorized to provide goods or services

15. Credit card record theft

16. Misconduct involving weapons

17. Misconduct involving explosives

18. Depositing explosives

19. Misconduct involving simulated explosives

20. Concealed weapon violation

21. Misdemeanor indecent exposure

22. Misdemeanor public sexual indecency

23. Aggravated criminal damage

24. Adding poison or other harmful substance to food, drink or medicine

25. A criminal offense involving criminal trespass under Title 13, Chapter 15

26. A criminal offense involving burglary under Title 13, Chapter 15

27. A criminal offense involving organized crime or fraud as prescribed in Title 13, Chapter 23, except terrorism

28. Misdemeanor offenses involving child neglect

29. Misdemeanor offenses involving contributing to the delinquency of a minor

30. Misdemeanor offenses involving domestic violence as defined in A.R.S. § 13-3601

31. Felony offenses involving domestic violence if the offense only involved criminal damage in the amount of

$250 but less than $1000 and the offense was committed before June 29, 2009

32. Arson

33. Criminal damage

34. Misappropriation of charter school monies as prescribed in A.R.S. § 13-1818

35. Taking identity of another person or entity

36. Aggravated taking identity of another person or entity

37. Trafficking in the identity of another person or entity

38. Cruelty to animals

39. Prostitution as described in A.R.S. § 13-3214

40. Sale or distribution of material harmful to minors through vending machines as prescribed in A.R.S. § 13-3513

41. Welfare fraud

42. Kidnapping

43. Robbery, aggravated robbery or armed robbery

44. Misdemeanor endangerment

45. Misdemeanor threatening or intimidating

CSO-1229A (1-16) - Page 5

YES NO

46. Misdemeanor assault

47. Misdemeanor aggravated assault

48. Misdemeanor unlawfully administering intoxicating liquor, narcotic drugs or dangerous drugs

49. Misdemeanor dangerous or deadly assault by prisoner or juvenile

50. Misdemeanor prisoners who commit assault with intent to incite riot or participate in riot

51. Misdemeanor assault by vicious animals

52. Misdemeanor drive-by shooting

53. Misdemeanor assaults on public safety employees or volunteers and state hospital employees

54. Misdemeanor discharging a firearm at a structure

55. Misdemeanor prisoner assault with bodily fluids

56. Misdemeanor aiming a laser pointer at a peace officer

57. Misdemeanor possession and sale of peyote

58. Misdemeanor possession and sale of a vapor-releasing substance containing a toxic substance

59. Misdemeanor selling or giving nitrous oxide to underage persons

60. Misdemeanor sale of regulated chemicals

61. Misdemeanor sale of precursor chemicals

62. Misdemeanor production or transportation of marijuana

63. Misdemeanor possession, use or sale of marijuana, dangerous drugs or narcotic drugs

64. Misdemeanor possession, use, administration, acquisition, sale, manufacture or transportation of prescription-only drugs

65. Misdemeanor administration, acquisition, manufacture or transportation of dangerous drugs or narcotic drugs

66. Misdemeanor manufacturing methamphetamine under circumstances that cause physical injury to a minor under the age of 15

67. Misdemeanor involving or using minors in drug offenses

68. Misdemeanor possession, use, sale or transfer of marijuana, peyote, prescription drugs, dangerous drugs, or narcotic drugs or manufacture of dangerous drugs in a drug-free school zone

69. Misdemeanor possession, manufacture, delivery and advertisement of drug paraphernalia

70. Misdemeanor use of wire communication or electronic communication in drug-related transactions

71. Misdemeanor using a building for sale or manufacture of dangerous or narcotic drugs

72. Misdemeanor manufacture or distribution of prescription-only drug

73. Misdemeanor manufacture, distribution, or possession with intent to use imitation controlled substances, imitation prescription-only drugs or imitation over-the-counter drugs

74. Misdemeanor manufacture of certain substances and drugs by certain means

Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, contact your local office; TTY/TDD Services: 7-1-1. • Free language assistance for Department services is available upon request.