If you are unable to fill out this form on-line, please click the link below, download it, fill it out, print and sign it, and then email it to your supervisor.

Disclosure Statement Form

  • Due to issues of liability and as required by State Law (RCW 43.43), we need to ask the following questions. A "Yes answer" will not necessarily disqualify you from consideration for the position for which you have applied. This information will be kept confidential.

  • Have you ever been convicted of any of the following crimes against children or other persons:

  • Have you ever been convicted of any of the following crimes related to financial exploitation of a person 60 years of age or older, who has a functional, mental or physical inability to care for him/herself or is a patient in a State hospital:

    *A "Dependency" is a proceeding usually brought by the State of Washington for the protection of children or incompetents from physical, mental or emotional abuse or neglect. See RCW 13.34 for more details.

  • UNDER PENALTY OF PERJURY, I certify that the above information is true, correct, and complete. I understand that if I am hired, I can be discharged for any misrepresentation or omission in the above statement. I also understand that if I am hired, my employment is conditioned on your receipt of a satisfactory report from the State Patrol.

  • MM slash DD slash YYYY

  • We may request your fingerprints to obtain from the State Patrol criminal identification system a report of your record of criminal convictions for offenses against persons, civil adjudications of child abuse, and disciplinary board final decisions. If you are hired before that report is available, YOUR EMPLOYMENT WILL BE CONDITIONED UPON THE RECEIPT OF A SATISFACTORY REPORT.

  • You will be notified of the State Patrol's response within 10 days after we receive the report. We will make a copy of the report available to you upon your request.