Section 7.36.F.1 - Professional Staff Certification and Credentialing Requirements
pursuant to a plea agreement committing, and am not now awaiting trial for committing, any of the following criminal offenses in the state of Arizona or similar offenses in any other jurisdiction, including a charge or conviction that has been vacated, set aside or expunged:
Subscribed, sworn to, and acknowledged before me by
____________________________, this _____ day of _________________, 20__,
in __________________________ County, Arizona.
My Commission Expires: ___________________
Reference: Section 7.36, Form 7.36.F.1