State of Florida

AFFIDAVIT OF GOOD MORAL CHARACTER

County of --,_--:- '

Before me this day personally appeared ,.-- ---,-;....,.,....------....,.... who, being duly, (Applicant's/Employee's Name)

sworn, deposes and says:

As an applicant for employment with, an employee of, a votunteerfor, or anapplicant to volunteer with '____________________ "_·'_,1 affirm arid attest under 'penalty of perjury 'that I'meet the moral character requirements for employment, as required by the Florida Statutes and rules, in that:

I have not been arrested' with· disposition' p~nqrng:or foGnd guilty of, regardless 9f;adjudicat'ion;;:Or entereda .. ' "','" !',. ',""','" ,~ ... -..••; .... --,.' ~ .. ""'? ";:"" ,', <_.. "'.','" _,.".',- .. ""'I't'" I,", ',', ~"' ••....':. -..."...",., .. ."~ _ ~,' --'. '-':"-'_'"'.'.~;"'_', ~.' ~. .'",.

plea of nolo cqnt~nderor 'g'Uilty'toorhav~be~h adWdic'ated'delinquent aha the record has-riot been sealed orexpunged for, any offense prohibited untieFany 'of the (o,,6WiA!;fpf6visiohs"dftheFldrida'Statute's' qruricier '~nysimilar statute of anothe:r jurisdJ'ction for anyqfthe qfferi~es::listea below': ,::: iF":", ' J ,j,,' ",':,(:,"; ,\ ' ;'" I'

.tr-. .i~...-:. -;,;r.t, ".<, : '1... 'i!~;_/L :.-~'~_:-,,...,-,,~.. ;:.~~.~~,:.~. ~ -. r :', '/:::,I'j c', ·"t'. I'; ~i '~"'o "",". t .:, .~

Section 393,135Section 394.4593Section 415.111Section 741.28Section 782,04Section 782.07

Section 782.071Section 782.09Chapter 784Section 784.011Section 784.03Section 787.01Section 787.02Section 787.025Section 787.04(2)Section 787,04(3)

Section 790.115(1)Section 790.115(2) (b)Section 794.011Former Section 794.041Section 794.05Chapter 796Section 798.Q2Chapter 800' :Section 806.01Section 810,02Section 810.14Section 810.145Chapter 8j2 . 'Section 817.563' 'Section 825.102Section 825,1025Section 825.: 103Section 826.04Section 827.03Section 827.04Former Section 827.05Section 827.071Section 843.01

" < J.' ". " ) J"Relatihl::rto:l"''''L ..,. ",,, Oli': '" ,f, "",1'cr, i

sexual misconduct with certain developmentally disabled clients and reportingiofsl'ieh §exual misconductsexual misconduct with certain mental health patients and reporting of such sexual misconductadult abuse, neglect, or exploitation of aged persons or disabled adults or (ailur~!o report of such abusecriminal offenses that constitute domestic violence,\AI~ethe.rcoll1m!ttedJfl F!oridaor another jurisdiction,murder " " , ".' , ". ;

,man~}augh,ter, .aggravated manslaughter of an elderly pers'on' or disabled adult, or aggravated manslaughter~a~~ , "

vehicular homicidekilling an unborn quick child by injury to the motherassault, battery, and .culpable.neqligence, if the .offenseytc;tq afelony.assault, if the victim of offense was a minor "'" ' ' ;",battery, if the victim of offense was a minor

,kidnappingfalse imprisonmentluring or enticing a child ,', .' ". .i;:.'taking, enticing, or removing a child beyond the state limits with criminal intent penqing custody proceedingcarrying a child beyond the state lines with criminal intent to Cjvo,ipproducing a child at a custody heariflg or

delivering the child to the desiqnatedperson '. , " 'exhibiting firearms or weaponswlthln 1,000 fe~tgf a schoolpossessing an electric weapon or device, destructive device, or other weapon on school propertysexual b~t~ery", ",l!"prohibited acts of persons in familial or custodial authorityunlawful sexual activity with certain minors 'prostitutionlewd and lascivious behavior

'.' leINdness and indecent exposurea'rson ' " - 'C" ' "

burglaryvoyeurism, if the offense is afelonyvideo voyeurism, if the offenseis a felony ,

, theft and/or robbery and related crimes, if a felony offensefraudulen! sale' of controlled substances': if the offerise'~was a'felonyabuse.iaqqravated abuse', or neglect of an elderly person or disabled adultlewd or jascivious offenses .committed upon or in the presence of an elderly person or disabled adultexploitation of disabled.adults or f1lderly persons, if the qffe,'nse was a felony,incest' " ," .child abuse, aggravated ctlildabuse,"or neglect ofa childcontributing' to the delinquency or dependency of a child-negligent treatment of children,sexual performance by a childresisting arrest with violence

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CONTINUED ON NEXT PAGECF 1649, Aug 2010 (Obsoletes previous editions which may not be used) Page 1 of 3

I attest that I have read the above carefully and state that my attestation here is true and correct that my "record does not contain any of the above listed offenses. I understand, under penalty of perjury, allemployees in such positions of trust or responsibility shall attest to meeting the requirements for qualifying foremployment and agreeing to inform the employer immediately if arrested for any of the disqualifying offenses.I also understand that it is my responsibility to obtain clarification on anything contained in this affidavit which Ido not understand prior to signing. I am aware that any omissions, falsifications, misstatements ormisrepresentations may disqualify me from employment consideration and, if I am hired, may be grounds fortermination or denial of an exemption at a later date.

SIGNATURE OF AFFIANT: _

Sign Above OR Below, DO NOT Sign Both Lines

To the best of my knowledge and belief, my record contains one or more of the applicable disqualifyingacts or offenses listed above. I have placed a check mark by the offense(s) contained in my record. (Ifyou have previously been granted an exemption for this disqualifying offense, please attach a copy of the lettergranting such exemption.) (Please circle the number which corresponds to the offense(s) contained in yourrecord.)

SIGNATURE OF AFFIANT: _

Sworn to and subscribed before me this __ day of , 20_.

SIGNATURE OF NOTARY PUBLIC, STATE OF FLORIDA

(Print, Type, or Stamp Commissioned Name of Notary Public)

(Check one)oAffiant personally known to notary

OR

oAffiant produced identificationType of identification produced: _

CF 1649. Aug 2010 (Obsoletes previous editions which may not be used) Page 3 of 3