(Please Print) Last First Middle
ADDRESS: _____________________________________________________ PHONE: ____________________
Street City State Zip
Explanation: All employment offers are subject to a background clearance which includes, at a minimum, a careful evaluation of
criminal history information to ensure prospective employees are clear of any criminal history that would indicate a risk to
the safety or security of the campus community. The District will not deny employment to any applicant solely because the
person has been convicted of a crime, however, applicants with convictions for any felony, any drug crimes and sex-related
crimes identified in Education Code 87010, 87011, and 88022 are not eligible for employment with the District. Failing to
list a conviction at the time the application is submitted may also be grounds for exclusion from employment. For all other
crimes, the District will consider the nature, date, and circumstances of the offense as well as whether the offense is
relevant to the duties of the position. All applicants who are offered employment will be provided with a LiveScan Request
Form and be required to submit fingerprints electronically at a California Department of Justice LiveScan location.
1. Have you ever been convicted (including a plea of guilty or no contest which resulted in a criminal conviction) of a
crime? (Exclude misdemeanor convictions for marijuana-related offenses more than two years old; notwithstanding any
of the preceding, you should not disclose convictions that are over two years old as of the date that you complete this
application for violation of health and safety code sections 11357, 11360, 11365, or 11550, as those statutes relate to
marijuana prior to January 1, 1976 or a statutory predecessor to those statutes.)
YES If YES, complete #2 and #3 below.
NO If NO, complete #3 below.
You must include a conviction even if you have received a release per section 1203.4 of the Penal Code.
You must include a conviction for a Vehicle Code violation if it resulted in a misdemeanor or felony conviction
(i.e. driving under the influence, hit and run, reckless driving).
You do not need to include a conviction for a Vehicle Code violation classified as an infraction or a parking
violation (i.e. speeding, running a stop sign, or a parking violation).
You do not need to include a conviction for an offense committed as a juvenile if the record has been sealed in
accordance with section 1203.45 of the Penal Code.
You do not need to include a conviction for a marijuana offense if the offense occurred more than two years ago
and the record has been expunged or is eligible to be expunged pursuant to section 11361.5 of the Health and
Safety Code.
2. List details of each conviction including offense date, arresting agency, code type and section violated, type of offense,
and date probation ends or ended.
Arresting Agency
(include City and State, i.e.,
Sacramento Police Department,
Sacramento CA)
Code Type and Section Violated
[include Code Type, i.e., P (Penal),
VC (Vehicle Code, H&S (Health &
Safety), etc., AND section of the code]
Type of Offense
(i.e., Infraction,
Misdemeanor or
Ends or Ended
3. By signing below, I certify that I have listed all of my criminal convictions except for those exempted by law, as noted
in #1. I understand that if I provide false information about a conviction or fail to disclose a conviction, I will be
disqualified for employment. I further understand that if a substantive error or omission of a conviction is revealed after
employment begins, I will be subject to immediate dismissal for cause.
Date:________________ Signed:____________________________________
P-881 (10/13) (This form will be kept confidential in the Human Resources Office)