Ancillary Services Criminal Affidavit - Cooperative Educational Services

Ancillary Services Application Criminal Affidavit

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Criminal Affidavit

To the Applicant:

Cooperative Educational Services (CES) assigns its Ancillary staff to school districts, charters and participating entities throughout the State of New Mexico. Your position as an Ancillary staff member involves contact with the student populations at these locations, including direct, unsupervised access to children with various forms of disability.

In order for CES to employ you in this capacity, you must provide the information requested below. This information is presented before your interview. Upon a successful interview, CES will conduct a social security and HB 128 2021 background checks. Final employment offer is contingent upon the results of the background checks.

Additionally, as a part of employment with CES, the district, charter, or participating entity you are assigned to will request completion of an additional fingerprint background check.

Any misrepresentation or omission of fact may be grounds for disqualification, termination or discharge, regardless of when the misrepresentation or omission is discovered.

Being charged with or convicted of a crime or any affirmative answer provided by you on this affidavit is NOT AN AUTOMATIC BAR to employment. CES will consider the nature of any conviction or alleged criminal conduct underlying the affirmative response, the date of the alleged criminal conduct in question, your intervening conduct, and the relationship between the offense or alleged conduct underlying the affirmative response and the position for which you are applying.

The crimes referred to in this document include but are not limited to:

Abandonment or abuse of a child
Sexual abuse of a minor
Incest of a minor
Sexual assault of a minor
Sexual exploitation of a minor
Sexual exploitation of a minor by prostitution
Contributing to the delinquency of a minor
Enticement of a child
Trafficking controlled substances
Distributing controlled substances to a minor
Delivery to a minor of drug paraphernalia
A dangerous crime against a child or children
Criminal sexual contact of a minor
Molestation of a child
Criminal sexual penetration
Criminal sexual conduct
Indecent exposure
Aggravated indecent exposure
Aggravated assault or a minor
Murder
Manslaughter
Kidnapping
Arson
Burglary
Robbery
Sale, delivery, display of Sexually oriented material to minors
Prostitution
Patronizing prostitutes
Promoting prostitution
Accepting earnings of a prostitute
D.U.I./D.W.I
Embezzlement
Fraud
Assault and/or Battery
Aggravated indecent oriented material to minors

Certification

Name(Required)

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Certification(Required)

I, (name above), in consideration of an Ancillary staff position with CES, certify that this document is true, accurate, and full disclosure of my criminal background history.

SECTION 1

Section 1: Certification(Required)

I certify that I am not awaiting trial on, I have never been charged with or convicted of, and/or have never admitted committing, any criminal offenses, in this state, or any similar offense or offenses in any other jurisdiction, and that I have never been put on, and am not currently on, probation in this jurisdiction or any other jurisdiction with regard to any such criminal charges.

*If you check this box then skip to the signature section below.

SECTION 2

Section 2: Certification(Required)

I certify that the answers given to the questions below and the statements I attach to this form provide a true, accurate, and complete account of any criminal offenses that I may have committed or been charged with in this state or any other jurisdiction.

1. Have you ever been charged with a crime, other than a minor traffic offense?(Required)

Yes

Provide in your own words the details explaining your "yes" answer.(Required)

Provide in your own words the details explaining your "yes" answer.

2. Have you ever been convicted of a crime, other than a minor traffic offense?(Required)

Yes

Provide in your own words the details explaining your "yes" answer.(Required)

Provide in your own words the details explaining your "yes" answer.

3. Have you ever entered a plea of guilty or a plea of no contest for any crime other than a minor traffic offense?(Required)

Yes

Provide in your own words the details explaining your "yes" answer.(Required)

Provide in your own words the details explaining your "yes" answer.

4. Has any court ever deferred further proceedings without entering a finding of guilty and placed you on probation or in a public service or education program for any crime other than a minor traffic offense?(Required)

Yes

Provide in your own words the details explaining your "yes" answer.(Required)

Provide in your own words the details explaining your "yes" answer.

Where you have answered “yes” to any question above, attach sheet(s) providing in your own words the details explaining your answer(s). Include the date of the charge, the offense charged, the court involved with its full address, the charge or case number and the disposition of the matter (e.g., conviction, acquittal, court documents, etc.) an provide court documents related to these offenses.

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Signature

I understand and agree that an offer of employment from CES is contingent upon the social security background check CES will conduct after a successful interview. Additionally, my placement within a district/charter or participating entity may be contingent upon a clear fingerprint background check completed with said district/charter or participating entity. I understand my employment may be terminated if any information is misrepresented in this affidavit. I understand by signing this document, I am authorizing CES to run a social security background check using my social security number. I understand the background checks will gather information from the Domestic Watch List, Nationwide Criminal Database, Sex Offender registry and a Social Security Number Trace. In connection with any request for or provision of such information, I expressly waive any claims, including without limitation defamation, emotional distress, invasion of privacy or interference with contractual relations that I might otherwise have against the District, its agents and officials or any provider of such information. I understand that all terms of employment or offers of employment are conditional until the required background investigation is complete. I have read this authorization and release of all claims, and I expressly agree to the terms set forth herein.

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Ancillary Services Application Criminal Affidavit

Criminal Affidavit

Certification

SECTION 1

SECTION 2

Signature

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