Your Name *

First Name

Last Name

Organization's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Former Employee Name *

First Name

Last Name

Beginning Date of Employment *

MM

DD

YYYY

Ending Date of Employment *

MM

DD

YYYY

Full Time or Part Time?

Full Time

Part Time

Contracted

Unsupervised access to children *

Has the employee ever been under investigation for, or has been found to have violated, any state or federal statute relating to child abuse or neglect, sexual misconduct or any sexual offense, including those offenses prohibited in Chapter 30, Article 3, 3A, 4, 6, 6A, 9, 37, 37A or 52 NMSA 1978, unless the allegations were false or unsubstantiated.

Yes

No

Ethics *

Has the employee ever been under investigation for, or found to have violated, any ethical rule or policy approved by a former employer that previously employed the applicant, unless the allegations were false or unsubstantiated?

Yes

No

Revocation of Certificate *

Has the employee ever had a professional license or certificate denied, suspended, surrendered or revoked due to a finding of child abuse or ethical misconduct or while allegations of child/adult abuse or ethical misconduct were pending or under investigation?

Yes

No