History of Non-Misconduct

Name

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I have not been shown by credible evidence (e.g., a court or jury, a department investigation, or other reliable evidence) to have abused, neglected, sexually assaulted, exploited, or deprived any person. As a result, has any person been subjected to serious injury of intentional or grossly negligent misconduct as evidence by an oral or written statement to this effect obtained at the time of application submission.

Employee Signature

Date

Witnessed by:

Agency Signature

Date

History of Non-Misconduct

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