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Please
read the instructions prior to
downloading the form. To request a
supply of the forms, please call
(717)783-6211.
1. Type
or print clearly and neatly in ink
Section I only.
2. Address must be
Applicant's current home address.
3. All information must be
completed in full. (The form asks
for all previous names, addresses,
and household members since 1975).
This information must be provided to
the best of your knowledge and
belief. If necessary, attach
additional pages.
4. Application must be
signed.
5.
Enclose a $10.00 money order
for each application. No cash or
personal checks accepted. Agency or
business checks are acceptable.
6. Do not send any postage
paid return envelopes.
7. Application should be
placed in a business-sized or larger
envelope prior to mailing.
8. One block must be checked
for Purpose for Clearance. Do not
check more than one block.
A. Check
the Volunteer Block if performing a
service (paid or unpaid) for
organizations such as Big
Brothers/Big Sisters, Boy Scouts,
Little League or churches. A copy of
your Criminal Record Check results
obtained within the past year must
be attached. Do not send original
Criminal Record results. If you are
not a
Pennsylvania
resident, you must also attach a
copy of your FBI results obtained
within the past year. This block
should not be checked for anyone
volunteering in schools.
B. Check the School Block if
seeking to have involvement within a
school (public, private vocational,
technical, nursing) for any reason.
C
C. Check the Foster Care
Block if applying for foster
parenting or custody of a child.
D. Check the Adoption Block
if in the process or planning to
adopt a child.
E. Check the Child Care
Block if planning to work in a day
care setting or if all other blocks
do not apply.
F. Check the CWEP Block if
you are participating in a
Department of Public Welfare
training program. The signature and
phone number of the County
Assistance Representative is
required.
Clearance
results will be mailed to you within
14 days from the date that the
clearance is received in our office.
There will be no replacements after
90 days. Failure to comply with the
above instructions will cause
considerable delay.
Please
contact the following for applicable
criminal history requests:
PA
Criminal Record Checks (SP4 164):
(717) 783-9973
FBI Cards for School Employees (FD
258): (717) 783-3750
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