YOUTH CENTER, CHILD DEVELOPMENT CENTER

AND SWIMMING POOL WORKSHEET

1. Applicants for positions that require working with children under the age of 18

must complete the following:

a. Have you ever been arrested for, or charged with, a crime involving a child?

YES_____ NO_____

b. If your answer is yes, provide a description of the disposition of the arrest or charge.

______________________________________________________________

______________________________________________________________

______________________________________________________________

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c. Have you ever been arrested for or charged with a crime involving drugs or alcohol?

YES_____ NO_____

d. If your answer is yes, provide a description of the disposition of the arrest or charge.

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

e. This is to advise you that, if you are accepted for employment, the

Air Force is required to request a National Agency Check as a condition

of employment. You have a right to obtain a copy of that report and to challenge
the accuracy of any information contained in the report.

2. You are signing this application under penalty of perjury. The penalty for

perjury is a $250,000 fine or 5 years in jail, or both.

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Signature Date