Admin: Annual Employee Disclosure For Licensing Renewal

Had a felony conviction under the uniform controlled substance act?(Required)
Had a misdemeanor or felony conviction of a crime against person, a sexual offense or crimes affecting family relationships and children?(Required)
Been adjudicated (found or determined in a court of law to be) a juvenile offender, delinquent, or miscreant?(Required)
Committed physical, mental or emotional abuse or neglect or sexual abuse as validated by DCF?(Required)
Had a child declared in a court order to be deprived or in need of care based on allegation of physical, mental or emotional abuse or neglect or sexual abuse?(Required)
Had parental rights terminated?(Required)
Signed a diversion agreement involving child abuse or a sexual offense?(Required)
Been found to be a disabled person in need of a guardian or conservator or both?(Required)
MM slash DD slash YYYY
Name(Required)