(1) 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.

(2) An offense under one or more of the following provisions of 18 Pa.C.S. (relating to crimes and offenses):

· Chapter 25 (relating to criminal homicide).
· Section 2702 (relating to aggravated assault).
· Section 2901 (relating to kidnapping).
· Section 2902 (relating to unlawful restraint).
· Section 3121 (relating to rape).
· Section 3122.1 (relating to statutory sexual assault).
· Section 3123 (relating to involuntary deviate sexual intercourse).
· Section 3124.1 (relating to sexual assault).
· Section 3125 (relating to aggravated indecent assault).
· Section 3126 (relating to indecent assault).
· Section 3127 (relating to indecent exposure).
· Section 3301 (relating to arson and related offenses).
· Section 3502 (relating to burglary).
· Section 3701 (relating to robbery).
· A felony offense under Chapter 39 (relating to theft and related offenses) or two or more misdemeanors under Chapter 39.
· Section 4101 (relating to forgery).
· Section 4114 (relating to securing execution of documents by deception).
· Section 4302 (relating to incest).
· Section 4303 (relating to concealing death of child).
· Section 4304 (relating to endangering welfare of children).
· Section 4305 (relating to dealing in infant children).
· Section 4952 (relating to intimidation of witnesses or victims).
· Section 4953 (relating to retaliation against witness or victim).
· A felony offense under section 5902(b) (relating to prostitution and related offenses).
· Section 5903(c) or (d) (relating to obscene and other sexual materials and performances).
· Section 6301 (relating to corruption of minors).
· Section 6312 (relating to sexual abuse of children).

(3) A Federal or out-of-State offense similar in nature to those crimes listed in paragraphs (1) and (2).

• I demonstrate rehabilitation by evidence of a minimum five-year aggregate work history in care-dependent services, without incident, from either the date of conviction or release from incarceration, whichever is later.
• I am responsible for providing official verification of such dates. Care-dependent services
include healthcare, eldercare, childcare, mental health, [intellectual disabilities], or care of the disabled.
• My employer must reasonably investigate the character of an individual with a previously disqualifying criminal offense by means of interviews, references and evidence of work history.
• My employer is required to obtain specific employer-provided documentation of my employment in care dependent services and retain it in my personnel file.
• My employer is required to notify me, in writing, if the decision not to hire me is based, in whole or in part, on my criminal history.

I hereby swear/affirm that the information as set forth above is true and correct. I understand that false swearing is a misdemeanor pursuant to Section 4903 of the Crimes Code.