We will consider the date facts and circumstances of each conviction or

We will consider the date facts and circumstances of

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We will consider the date, facts, and circumstances of each conviction or forfeiture you list. In most cases, you can still be considered for District employment. During the past 10 yearso have you beenz Qfi.onvicted of or forfeited collateral for any felony; or (2) './' convicted by a court-martial?ffi Ves E *o Afelony is defined as any violation of law punishable by imprisonment of longer than one year, but does not include a misdemeenor under state, county, or local law, punishable by imprisonment of two years or less. trf "9rlu ilnslvered *tFS'" to the Q{JESTION *rtroveo y$u are allnlved an cppnrtunit.y tu e.rplnin your resp*nse. For each *f y*rlr cernviction{s}, ;:l*ase slate the l'*llcwing: {1) cfi'ense{s) of whie h ysu *'ere convictedl {2} the clate of the convictiou(s); {3} fhe stnte or territory rvhere the ronviction{s} occurretl; {4} tkc c*urti and {5) any actionts) takcxr by the conrt against you, includiftg any sentenccu or probation iaarposcd. illeas* prerviele any aeltlitional explanati*n -v*u wr:xrld like us to csnsidcr. YOU MUST SIGN THIS FORM. Read the following acknowledgement carefully before you sign. I understand that a false statement on any part of this form is grounds for either not hiring me, or firing me afterlbeginwork(D.C.OffrcialCode$ 1-616.51, etseq.) (2001).Iunderstandthatthemakingofafalse statement on this form or materials submitted with this form is punishable by criminal penalties pursuant to D.C. Offrcial Code $ 22-2405, et seq. (2001). I understand that any information I give may be investigated as allowed by law or Mayoral Order. I consent to the release of information regarding my suitability for District of Columbia govemment employment by employers, schools, law enforcement agencies, and other individuals and organizations, to investigators, human resources specialists, and other authorized employees of the District of Columbia government. I certifu that, to the best of my knowledge D.C. Standard Form No. 04-10 (lssued 6/l l) ts are true, correct, and complete.
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GOVERNMENT OF THE DISTRICT OF COLUMBIA D.C. Department of Human Resources AUTHORIZATION F'OR RELEASE OF INF'ORMATION FOR PRE-EMPLOYMENT CHECK [Carefully read this authorization to release information about you, then sign and date it in ink.] Name: Date of Birth: *Social Security Number: ;Yl -c! * 11s+ Place of Birth: Home Address: .\ F (t'sa'ft (0r a This release, as transmitted to me by a duly authorized representative of the DOES (DCHR or Employing Agency) constitutes my consent and authority to the District govemment to examine and obtain copies, abstracts of records, or receive statements and information regarding my background. Specifically, I hereby authorize the release of the following information or records to a duly authorized representative of the District govemment agency considering me for employment: a.
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  • Spring '12
  • janigrt
  • Federal government of the United States, Authorization, Washington, D.C., District Government, D.C. Standard Form

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