EmailMe Form - Background Check Clearance Submissions for WRA

Name *

First Middle Last Suffix

Home Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Primary Phone *

### - ### - ####

Email Address *

Confirm Email by re-entering below:

State Police Clearance Date *

MM / DD / YYYY

Enter the effective date of your Report of Criminal History from the Pennsylvania State Police.

Child Abuse Clearance Date *

MM / DD / YYYY

Enter the Verification date of your Report of Criminal History from the Pennsylvania Child Abuse History Clearance from the Pennsylvania State Police.

Disclosure Date

MM / DD / YYYY

Enter the effective date of your Disclosure Statement for Volunteers.

FBI Clearance Date

MM / DD / YYYY

Enter the effective date of your Fingerprint based FBI Criminal History Clearance.

State Police Clearance Upload *

Upload Report of Criminal History from the Pennsylvania State Police. Choose your saved .PDF file from the state and click on the Upload button.

Upload Child Abuse Clearance *

Choose your saved .PDF file from the PA Dept of Human Services and click on the Upload button.

Upload Disclosure Statement, if you have lived in PA continuously for the past 10 years.

A blank Disclosure Statement can be found by clicking here.

Upload FBI Clearance, if you have NOT lived in PA continuously for the past 10 years.

Upload Fingerprint based FBI Criminal History Clearnance through the Department of Human Services

WRA Background Check Submission ID#