Revised 12/08

Employment Disclosure Statement

Pursuant to Chapter 43.43 RCW

Please answer YES

or

NO

to each listed item. If the answer is

YES

to any item, explain in the area

provided. Indicate the charge or finding, the date, and the court(s) involved. If you do not understand the

following questions or if you are uncertain as to your answer to those questions, do not complete this

form until such time as you are certain as to your response.

1. Have you

ever

been convicted of any crime? The term "

convicted"

means all adverse dispositions,

including a finding of guilty, a plea of guilty, a plea of guilty or nolo contendere, an Alford plea,

stipulation to the facts, a deferred or suspended sentence, or a deferred prosecution.

‰

Yes

‰

No.

If yes, explain: ___________________________________________________________

2. Have you

ever

had findings made against you in any civil adjudicative proceeding? "

Civil

adjudicative proceeding

" means any judicial or administrative adjudicative proceeding that results

in a finding of, or upholds an agency finding of, domestic violence, abuse, sexual abuse, neglect, or

exploitation or financial exploitation of a child or vulnerable adult under Chapters 13.34, 26.44, or

74.34 RCW, or rules adopted under Chapters 18.51 and 74.42 RCW

. "Civil adjudicative

proceeding"

also includes judicial or administrative orders that become final due to the failure of the

alleged perpetrator to timely exercise a right afforded to him/her to administratively challenge

findings made by the Department of Social and Health Services or the Department of Health under

Chapters 13.34, 26.44, or 74.34 RCW, or rules adopted under Chapters 18.51 and 74.42 RCW.

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‰

Yes

‰

No.

If yes, explain: ___________________________________________________________

3. Have you

ever

been the subject of a complaint made to the Office of the Superintendent of Public

Instruction regarding whether you have committed an act of unprofessional conduct, as defined in

WAC 181-187, or whether you are a person of good moral character and personal fitness as defined

in WAC 181-79A-155?

‰

Yes

‰

No.

If yes, explain: ___________________________________________________________

Pursuant to RCW 9A.72.085, I certify under penalty of perjury under the laws of the State of Washington

that the foregoing is true, correct, and complete. I agree that if I have provided false, misleading or

incomplete information, the District may, at its sole discretion, terminate my employment. If such action

is taken by the District, I agree that any employment contract or employment relationship deemed to exist

shall be void from its inception. It is understood that this statement and record become the property of

the Everett School District. A criminal history check may be requested through the Washington State

Patrol or federal law enforcement agencies.

Name (please print): _________________________________________________________________

Signature: _________________________________________ Date: _________________________