In Process 2 of 2 ii. An offense designated as a felony under the act of April 14, 1972 (P.L. 233, No. 64), known as “The Controlled Substance, Drug, Device and Cosmetic Act,” committed within the preceding five-year period. iii. A founded report or indicated report of child abuse within the preceding five-year period in the statewide database maintained by the Department of Human Services. iv. Identification on the National Crime Information Center National Sex Offender Registry or on a state's sex offender registry Section 3. Certification By signing this form, I swear and affirm under penalty of law that the statements made in this form are true, accurate, correct, and complete. I understand that false statements herein, including, without limitation, any failure to accurately report any arrest or conviction for a Reportable Offense, shall subject me to criminal prosecution under 18 Pa.C.S. §4904, relating to unsworn falsification to authorities. _____________________________________________________ _____________________________________ Volunteer’s Signature Date If less than 10 years at current address, provide prior Pennsylvania addresses here: Docusign Envelope ID: DEAEB2A8-63E7-4877-B042-5014B6911E48
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