Employer Fingerprint Clearance Certification

I certify that I, the owner or authorized representative of ___________________________________________ (company), have conducted a criminal background check of all employees and volunteers (18+ years old) who will have contact with JCS, Inc. students, through the Department of Justice (DOJ), in accordance with Education Code §45125.1.

I additionally certify to JCS, Inc. that no employee or volunteer (18+ years old) of ________________________________ (company) working with students of JCS, Inc. has been convicted of a violent or serious felony as defined by statute, nor has a criminal action pending upon charges of commission of a violent or serious felony as defined by statute.

________________________________________	______________________________
Owner or Authorized Representative Signature	Date

________________________________________	______________________________
Print Name	Title

Please list all employees or volunteers (18+ years) who will come in contact with JCS-Inc. students. You may attach another sheet if necessary.

❑ CDE-NPA Cert exp date ❑ DOJ-ORI Acct #

(attach copy)