Legal Arrest or Conviction Form

LEGAL ARREST OR CONVICTION FORM

This Legal Arrest or Conviction Form (the "Form") is executed between Requesting Entity: and Applicant Name: . The parties agree that the Applicant will make the disclosures and certifications contained herein to permit the Requesting Entity to evaluate the Applicant's arrest and conviction history for lawful purposes.

RECITALS

WHEREAS, the Requesting Entity requires information regarding criminal arrests, charges, and convictions as part of its assessment for employment, licensure, placement, or other legal eligibility determinations; and

WHEREAS, the Applicant is willing to disclose all relevant arrests, charges, convictions, and the current status of any such matters and to authorize the Requesting Entity to obtain and verify criminal history records where permitted by law; and

WHEREAS, the parties desire to set forth the terms under which such information will be disclosed, used, and retained.

NOW THEREFORE

In consideration of the mutual covenants in this Form and other good and valuable consideration, the parties agree as follows.

1. DEFINITIONS

For purposes of this Form: "Arrest" means any custodial or non-custodial detention by law enforcement formally recorded; "Charge" means any criminal allegation filed in a court or by prosecuting authority; "Conviction" means a judgment of guilt by plea, jury or bench trial, or entry of a guilty plea pursuant to a plea agreement; "Expunged or Sealed" means any court order physically or electronically removing records from public access.

2. APPLICANT DISCLOSURE

Applicant shall truthfully disclose below all arrests, pending charges, and convictions that are not legally sealed or expunged and shall indicate whether any listed matter has been expunged or sealed. The Applicant certifies that the information provided is true, complete, and correct to the best of Applicant's knowledge. Applicant acknowledges that failure to disclose required matters or making a materially false statement may result in adverse action including denial of eligibility, rescission of an offer, or termination of a relationship with the Requesting Entity, and may subject the Applicant to civil or criminal penalties under applicable law.

No arrests, charges, or convictions to disclose

If disclosing, provide details for each incident. Provide all applicable dates, jurisdictions, and case numbers. Attach additional sheets if necessary.

3. INCIDENT 1

Arrest/Charge Date:

Disposition (plea, conviction, dismissal, sentence):

Record Status: Convicted Dismissed Pending Expunged/Sealed

4. ADDITIONAL INCIDENTS

If more incidents exist, provide additional information below. Attach extra pages as needed and initial each additional page.

Arrest/Charge Date:

Arrest/Charge Date:

5. CONSENT TO OBTAIN RECORDS AND RELEASE

Applicant hereby authorizes the Requesting Entity and its agents to obtain criminal history records, court records, and other information necessary to verify the disclosures set forth in this Form. Applicant authorizes any law enforcement agency, court, correctional institution, or other entity to release such records to the Requesting Entity. Applicant releases and holds harmless the Requesting Entity and its officers, employees, and agents from any liability arising from the obtaining, receiving, or use of such records to the extent permitted by law.

6. ACCURACY; CERTIFICATION

Applicant certifies under penalty of perjury that the statements contained in this Form are true, correct, and complete. Applicant understands that any material misrepresentation or deliberate omission may constitute grounds for denial of an application, termination of an offer, or other adverse action, and may expose Applicant to civil or criminal penalties.

7. USE, RETENTION, AND CONFIDENTIALITY OF RECORDS

The Requesting Entity will use disclosed and obtained records solely for lawful purposes connected to its evaluation of Applicant. The Requesting Entity agrees to retain such records in a secure manner and to limit access to authorized personnel. Where applicable law requires destruction, sealing, or restricted use of records, the Requesting Entity shall comply with such legal obligations.

8. REPRESENTATIONS; INDEMNITY

Applicant represents that Applicant has the full right and authority to execute this Form. Applicant agrees to indemnify and hold harmless the Requesting Entity from any claims arising out of Applicant's failure to disclose material information or from Applicant's misrepresentations to third parties to the extent such claims result from Applicant's conduct.

9. NOTICES

All notices under this Form shall be in writing and delivered to the addresses below by hand, certified mail, or courier. Notice is effective upon receipt.

10. AMENDMENTS; WAIVER; COUNTERPARTS

Any amendment to this Form must be in writing and signed by both parties. Failure to enforce any provision shall not constitute a waiver of that provision. This Form may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one instrument.

11. GOVERNING LAW; SEVERABILITY; ENTIRE AGREEMENT

This Form shall be governed by and construed in accordance with the laws of the state identified by the Requesting Entity in its internal policies and practices as applicable to the transaction. If any provision is held invalid, the remainder of the Form shall remain in full force and effect. This Form constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior agreements and understandings, whether written or oral, relating to such subject matter.

12. ACKNOWLEDGMENT

Applicant acknowledges receipt of a copy of this Form and certifies that Applicant has read and understands the content and legal consequences of the disclosures, consents, and certifications made herein.

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