CRIMINAL BEHAVIOR DISCLOSURE

Candidates applying to work in the city of Newark, NJ: Do not complete this form.
It is the policy of Kelly Services to consider for employment all qualified individuals, including those with prior criminal behavior, pending criminal
charges, deferred prosecutions, or alternative criminal proceedings. A conviction record does not automatically bar candidates from employment;
all job-related circumstances surrounding criminal behavior disclosure will be considered. Kelly prohibits making a decision not to hire or assign an
applicant who discloses criminal behavior prior to reviewing the behavior, timeline, and status associated with the individuals disclosure.

When completing this section, do not disclose information regarding convictions that have been judicially sealed, expunged, eradicated,
impounded, pardoned, dismissed, or nulled. Do not disclose information regarding juvenile court convictions or minor traffic violations.
However, an answer is required for all three questions.
Applicants in California: Do not disclose information regarding any referral to, or participation in, a pre- or post-trial diversion program. Also, do
not disclose information regarding any marijuana-related convictions under California Health and Safety Code sections 11357(b)-(e) or 11360(b) that
are more than two (2) years old.
Applicants in Connecticut: You need not disclose any conviction record that has been erased pursuant to sections 46b-146, 54-76o or 54-142a
of the Connecticut General Statutes. Records subject to erasure under these sections are records pertaining to a finding of delinquency or that a
child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that was dismissed or nulled, or a
criminal charge for which the person was found not guilty or received an absolute pardoned conviction. Any person whose records were erased
within the meaning of these three sections may consider such events to have never occurred and may so swear under oath.
Applicants in Georgia: Do not disclose any first offender discharge as described under Georgia Law.
Applicants in M assachusetts: Do not disclose information regarding misdemeanor convictions or completion of any incarceration that is more
than five (5) years old and first convictions for drunkenness, simple assault, an affray, or disturbing the peace.
Applicants in Nevada: Do not disclose misdemeanor convictions that did not result in imprisonment.

1. In the last seven (7) years, have you been convicted of, pled guilty or no contest to, been imprisoned for, or been on probation or
parole for any felony?

Yes No or No Record

2. In the last seven (7) years, have you been convicted of, pled guilty or no contest to, been imprisoned for, or been on probation or
parole for any misdemeanor?

Yes No or No Record

3. If you answered:
N o to both number 1 and 2 above, check this box. N/A
Yes to either of the above questions, please explain completely. Provide city, county, and state of conviction, plus date and nature of
the offense, along with sentencing information. (If you are completing this form by hand and need more space, enter additional
information on the back of this sheet).
I was charged with a theft charge and it was a misdamenor and I had to do three days in jail last year.

Provide any additional information, evidence of rehabilitation, and/or other mitigating factors you would like considered in your overall
individualized analysis. (If you are completing this form by hand and need more space, enter additional information on the back of this
sheet).

I acknowledge that the information herein is true, accurate, and complete to the best of my knowledge, and that any omission or falsification of
this or any other information in the hiring process will be grounds for my elimination from consideration, or if I am hired, termination, regardless
of when discovered by Kelly. I further acknowledge that I completed this form after having been interviewed and given a conditional offer of
employment.
Tina M Candia
Name (Printed)

_____ / _____ / _____

Signature Date

Electronic Signature* Date

*If you are submitting this form electronically, type your name on the Electronic Signature line and
check the box to the right next to I agree. This is your electronic signature. By electronically I agree.
signing this form, you agree that you have reviewed this entire form and agree to all the terms
contained in it.

2014 Kelly Services, Inc. An Equal Opportunity Employer e541 R8/14