N.J. Admin. Code § 10:48A-3 app APPENDIX
CERTIFICATION AND PERMISSION FOR BACKGROUND CHECK AND RELEASE OF INFORMATION
I hereby authorize the Department of Human Services to conduct a criminal history background check and I agree to be fingerprinted in order to complete the State and Federal background check process. I further authorize the release of all information regarding the results of my background check to the Department of Human Services. Check one of the options listed below.
Option 1 _____I hereby certify under penalties of perjury, that I have not been convicted of any of the offenses listed below and no such record exists in the State Bureau of Identification in the Division of State Police or in the Federal Bureau of Investigation, Identification Division.
Option 2 _____ I hereby affirm that I have been convicted
of the following offense listed below _____________________
on ___________________
(date)
If I have checked Option 2 or the criminal history background check reveals any conviction(s) for the offenses listed below, I understand that I may be subject to termination from employment, or if I am associated with a community care residence, the residence will not be qualified to house individuals.
FOR PROVISIONAL EMPLOYEES ONLY: As a provisional employee, I further understand that I may be employed by the agency for a period not to exceed six months during which time a background check will be completed. I understand that I will work under the supervision of a superior where possible.
Offenses covered under P.L. 1999, c. 358:
In New Jersey, any crime or disorderly person offense:
--involving danger to the person as set forth in N.J.S.A. 2C:11-1 et seq. through 2C:15-1 et seq. including the following:
i. Murder
ii. Manslaughter
iii. Death by auto
iv. Simple assault
v. Aggravated assault
vi. Recklessly endangering another person
vii. Terroristic threats
viii. Kidnapping
ix. Interference with custody of children
x. Sexual assault
xi. Criminal sexual contact
xii. Lewdness
xiii. Robbery
--against the children or incompetents as set forth in N.J.S.A. 2C:24-1 et seq. including the following:
i. Endangering the welfare of a child
ii. Endangering the welfare of an incompetent person
--a crime or offense involving the manufacture, transportation, sale, possession or habitual use of a controlled dangerous substance as defined in N.J.S.A. 2C:24-1 et seq.
--in any other state or jurisdiction, conduct which, if committed in New Jersey, would constitute any of the crimes or disorderly persons offenses described above.
FOR COMMUNITY AGENCY HEAD: I understand the results of this background check will be reported to the President of the Board of my agency.
PLEASE LIST THE NAME AND HOME OR BUSINESS ADDRESS OF THE BOARD PRESIDENT.
____________________________________
____________________________________
____________________________________
_________ _______________ ____________
Name (please print) Signature Date
_________ _______________ ____________
Witnessed by (please print) Witness Signature Date
N.J. Admin. Code 10:48A-3 app APPENDIX