By signing thisform, I affirm and attest that I meet the Moral Character requirementsfor employment asrequired pursuant to Chapter 435, Florida Statutes, and Section 393.0655, Florida Statutes.

The following acknowledgements apply to all Direct Service Providers and/or Employees, Contract Providers, and Volunteers. Please initial each statement.

I attest that I have read the above carefully and state that my attestation here is true and correct and that my record does not contain any of the above listed offenses. I understand, under penalty of perjury, all employees in such positions of trust or responsibility shall attest to meeting the requirements to the background screening standardsset forth in Chapter 435 and Section 393.0655.

My record contains one or more of the applicable disqualifying acts or offenseslisted above

Note: If you have previously been granted an APD exemption for this disqualifying offense, a copy of the APD exemption letter must be attached.

I am a licensed physician, licensed nurse, or other professional licensed and regulated by the Department of Health. I will be holding a position that is within the scope of my licensed practice, and I am notsubject to the screening provisions ofsection 393.0655, Florida Statutes.