Back Print form ___________________________________________________ Type or Print Name of Parish/School/Pre-School ____________________________________________________ Type or Print Street Address of Parish/School/Pre-School ____________________________________________________ Type or Print City, State, Zip Code of Parish/School/Pre-School * * * * * * * * * * * * * ******************************************* COMMONWEALTH OF PENNSYLVANIA )                                                                          ) SS: COUNTY OF ________________________ ) AFFIDAVIT OF COMPLIANCE CONCERNING CRIMINAL RECORD CHECK AND CHILD ABUSE HISTORY CLEARANCE          The undersigned, being duly sworn according to law, does depose and state that the following is true and correct:          1. I am a management level employee and duly authorized representative of the below named vendor of goods and/or services, or independent contractor, to the parish/school/pre-school named above.          2. I have been duly authorized by my employer to execute this Affidavit on behalf of my employer and to bind my employer to the terms, conditions and requirements of this Affidavit.         3. I acknowledge that my employer and I have been informed that as a condition of doing business, and continuing to do business, with the above named parish/school/pre-school, that I must complete background evaluations for all employees and other duly authorized representatives of my employer, who will in any way come into contact with children and young people of the parish/school/pre-school.         4. The background evaluations to be completed, paid for, filed with the authorities, written responses obtained from the authorities and the originals or copies of such written responses to be retained in our files concerning the subject employees before any employee and other authorized representative of my employer are permitted to come into contact with children and young people of the parish/school/pre-school, shall consist of the following:         A. "Request for Criminal Record Check" (form SP4-164 one page               form) to be submitted to the Pennsylvania State Police for each such person (sample attached hereto               as Exhibit "A") and, B. "Pennsylvania Child Abuse History Clearance" request (form CY-113 two page form) to be       submitted to the Childline and Abuse Registry of the Pennsylvania Department of Public Welfare       for each such person (sample attached hereto as Exhibit "B").       5. I acknowledge and agree to immediately notify the above named parish/school/pre-school if the criminal records check discloses a criminal record and/or the child abuse history clearance check discloses that an employee is listed in a report of child abuse. I also acknowledge and agree that we will not send the subject employee to the parish/school/pre-school.       6. I acknowledge and agree, that if the parish/school/pre-school requests copies of the criminal record checks and child abuse history clearance checks on any or all of our employees, that we will provide copies upon receipt of such request.       7. I acknowledge and agree that all criminal record checks and child abuse history clearance checks on our employees will be not more than twelve (12) months old, if the same pre-date this Affidavit.       8. I acknowledge that my employer and I have been informed that this is an ongoing responsibility, and that any new or additional personnel or other authorized representatives of my employer shall be subject to the same above referenced background evaluations.       9. I acknowledge that my employer and I have been informed that failure to comply with these requirements may lead to a termination of my employer's business relationship with the parish/school/pre-school.       10. In order to induce the parish/school/pre-school to continue our business relationship, I warrant and represent to the parish/school/pre-school that we intend to undertake all actions necessary to achieve immediate compliance with the above requirements, and that the parish/school/pre-school may rely upon this Affidavit and the warranties and representations set forth herein. I have read the above and it is true and correct. ____________________________________________________ Signature of Management Level Employee of Vendor or Independent Contractor _____________________________________________________ Print Name of Person Signing _____________________________________________________ Name of Vendor of Goods and/or Services or Independent Contractor _____________________________________________________ Address of Vendor or Independent Contractor _____________________________________________________ Telephone Number of Vendor or Independent Contractor _____________________________________________________ Brief Description of Goods and/or Services Furnished by Vendor or Independent Contractor SWORN TO and subscribed before me this _______ day of ___________________, 20___. ______________________________(SEAL) NOTARY PUBLIC My Commission Expires: ______________________________         Post Office Box F  •  Allentown, PA  •  18105-1538 Copyright 2003 The Catholic Diocese of Allentown Disclaimer and Terms of Use