Governing Board Members Application

Referral Source
- Advertisement
- Staff
- Board Member
- Website
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I am available to meet
From:

: Hours

Minutes

AM/PM
Until:

: Hours

Minutes

AM/PM
Email*
Phone
Best time to call
Occupation
Have you been convicted of a felony within the last 7 years?*
- Yes
- No
(Such convictions may be relevant if job related, but do not bar you from employment.)
If yes, please explain.

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Signature: I certify that the answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not and is not intended to be a contract. In the event of membership, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the agency.*
Date*
MM slash DD slash YYYY
Declaration Form

(Criminal, Child Abuse & Violent Felony Charges & Convictions)

Federal policies mandate that all prospective employees sign a declaration prior to employment, which lists:
1) All pending and prior criminal arrests and charges related to child sexual abuse and their disposition.
2) Convictions related to other forms of child abuse and/or neglect; and
3) All convictions of violent felonies.

The declaration may exclude:
1) Traffic fines of $200 or less;
2) Any offense, other than any offense related to child abuse and/or child sexual abuse or violent felonies, committed before the prospective employee’s 18th birthday which was finally adjudicated in a juvenile court or under a youth offender law;
3) Any conviction the record of which has been expunged under Federal or State law; and
4) Any conviction set aside under the Federal Youth Corrections Act or similar State authority.

Note: Individuals who declare, through this form, that they have been arrested, charged with or convicted of any of the offenses listed above are not automatically disqualified. CAPCA will review each case to assess the relevance of an arrest, charge or conviction prior to a hiring decision.
Please select the appropriate option below:*
- I have not been arrested, charged and/or convicted of one or more of the three types of offenses listed above
- I have been arrested, charged and/or convicted of one or more of the three types of offenses listed above. If so, please attach information listing the offense(s), the date(s) of the arrest, charge, and/or conviction, and other relevant information.
Date*
MM slash DD slash YYYY
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Governing Board Members Application

Board Member Application

Step 1 of 4

Education - High School

Education - Business, Trade, or Technical

Education - College

Education - Graduate School

Declaration Form

(Criminal, Child Abuse & Violent Felony Charges & Convictions)

Name	Address	Phone Number