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Admin: Employee and Board Member Disclosure Statement and Agreement
In accordance with 22 CFR 96, Section 96.35 Hague Accreditation; Adoption & Beyond, Inc. agrees to disclose unfavorable information about its individual board members and employees. Please complete this form and explain any answers. This form will be kept in your file at Adoption & Beyond, Inc. and will be provided to the accrediting entity and its agent(s) upon request. Please select Yes, No or N/A and explain any Yes answers:
For the prior ten-year period, have you taken part in any conduct related to the provision of adoption-related services that was subject to external disciplinary proceeding(s)?
(Required)
Yes
No
N/A
Please Explain
Have any convictions or current investigations for acts involving financial irregularities? (Applies to any individual in a senior financial management position)
(Required)
Yes
No
N/A
Please Explain
Taken part in any business or activities that are inconsistent with the principles of the Convention and which is currently being carried out?
(Required)
Yes
No
N/A
Please Explain
Been arrested, convicted or otherwise committed any crimes, especially related to child abuse and/or domestic violence?
(Required)
Yes
No
N/A
Please Explain
Consent
(Required)
With my signature below, I attest that the information above is correct to the best of my knowledge, and I also agree to disclose any changes in the above information immediately in order to permit the accrediting entity to monitor the suitability of Adoption & Beyond, Inc. I understand that Adoption & Beyond, Inc. will be required to disclose this change to the accrediting entity within thirty (30) days.
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(Required)
Date
(Required)
MM slash DD slash YYYY
Name
(Required)
First
Last
Title
(Required)
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