CRIMINAL CONVICTION INFORMATION SHEET

As you know, within the application/employment process, you indicated you have been convicted of a crime. A criminal
conviction does not necessarily bar you from employment with Kelly Services, Inc. (Kelly).
When evaluating your employment information, Kelly will review the facts and circumstances of your conduct to
determine whether the conduct is substantially related to employment with Kelly. In order to allow Kelly to assess the
behavior related to your criminal conviction, please answer all questions listed below.
It is important that you provide an answer to each question and that your responses are complete and accurate.
When you have completed the questions, please sign and date this form and return to your Kelly representative
for further instructions.
Note: If you have been convicted of more than one offense, please complete the attached Additional Offense(s)
Sheet for each offense.

Offense 1
1. What is the offense for which you were convicted? A theft charge at a doller general store
2. What is the date of conviction? Date 03/15/2013
/ /
3. Indicate the type of offense. Felony Misdemeanor
4. Provide the facts and circumstances of each offense, including what happened and where (county and state) it
happened. If additional space is needed, please use extra paper.

The county was Putnam and the state was Ohio, it was a theft charge at the Dollar General in Ottawa,Ohio

5. Were you a juvenile when you committed the offense? Yes No

6. Did you act alone when committing the offense? Yes No
7. What was your sentence? If time was served in prison, indicate the sentence, how much time you served, and the
name and location of the prison facility.
Putnam County Jail in Ottawa, Ohio

Offense 1 (Continued)
8. Are you currently subject to any sentencing restrictions?
If Yes, explain and indicate if you are currently on probation, living in a half-way Yes No
house, on a tether, or restricted from engaging in specific activities.
I am not allowed to go shop at the Dollar General where the theft charge happened.

9. Are you currently on probation/parole? If yes, complete the following:

Yes No
Probation/Parole Officers Name: _______________________________
Phone Number: ___ / __ ___ / ____

10. Have you received recognition for good conduct and/or completed any
Yes No
rehabilitation since your conviction? If Yes, explain.

2014 Kelly Services, Inc. An Equal Opportunity Employer e2382 R3/14

Page 1 of 11
 Connecticut Kelly Educational Staffing Individuals: Complete only if seeking Kelly Educational Staffing
assignments.
1. Have you ever been convicted in Connecticut or anywhere else of any felonies
and/or misdemeanors?
Yes No
If Yes, please follow the instructions on page 1 to provide information on
the conviction.
2. Are criminal charges currently pending against you for any offense?
If Yes, provide details relating to the charge(s) pending against you. Provide the
name of the offense, type and degree of the charge, where the charges are Yes No
pending, (state, county, and city), the name of the court in which the charges are
pending, and the facts concerning the charges.

I hereby consent to a criminal history record check and to be fingerprinted for the purpose of the Federal
Bureau of Investigation criminal history check.
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CONNECTICUT THAT THE ABOVE
IS TRUE AND CORRECT.

I certify that the information on this form (and any related attachments) is true and complete. I understand that my
failure to completely and truthfully respond to all questions may result in employment disqualification.

Tina Candia
Name (Printed): _____________________________ __________

Signature: __________________________________________________________________

9771
Last four digits of Social Security Number:

Date:

2014 Kelly Services, Inc. An Equal Opportunity Employer e2382 R3/14

Page 2 of 11
 ADDITIONAL OFFENSE(S) SHEET
If convicted of more than one offense, complete one of these sheets for each additional offense upon which you were convicted.

Offense # 2
1. What is the offense for which you were convicted?
2. What is the date of conviction? / /
3. Indicate the type of offense. Felony Misdemeanor
4. Provide the facts and circumstances of each offense, including what happened and where (county and state) it
happened. If additional space is needed, please use extra paper.

5. Were you a juvenile when you committed the offense? Yes No

6. Did you act alone when committing the offense? Yes No
7. What was your sentence? If time was served in prison, indicate the sentence, how much time you served, and the
name and location of the prison facility.

8. Are you currently subject to any sentencing restrictions?

If Yes, explain and indicate if you are currently on probation, living in a half-way Yes No
house, on a tether, or restricted from engaging in specific activities.

9. Are you currently on probation/parole? If yes, complete the following: Yes No

Probation/Parole Officers Name: _______________________________
Phone Number: ___ / __ ___ / ____

10. Have you received recognition for good conduct and/or completed any
Yes No
rehabilitation since your conviction? If Yes, explain.

2014 Kelly Services, Inc. An Equal Opportunity Employer e2382 R3/14

Page 3 of 11
 ADDITIONAL OFFENSE(S) SHEET
If convicted of more than one offense, complete one of these sheets for each additional offense upon which you were convicted.

Offense # 3
1. What is the offense for which you were convicted?
2. What is the date of conviction? / /
3. Indicate the type of offense. Felony Misdemeanor
4. Provide the facts and circumstances of each offense, including what happened and where (county and state) it
happened. If additional space is needed, please use extra paper.

5. Were you a juvenile when you committed the offense? Yes No

6. Did you act alone when committing the offense? Yes No
7. What was your sentence? If time was served in prison, indicate the sentence, how much time you served, and the
name and location of the prison facility.

8. Are you currently subject to any sentencing restrictions?

If Yes, explain and indicate if you are currently on probation, living in a half-way Yes No
house, on a tether, or restricted from engaging in specific activities.

9. Are you currently on probation/parole? If yes, complete the following: Yes No

Probation/Parole Officers Name: _______________________________
Phone Number: ___ / __ ___ / ____

10. Have you received recognition for good conduct and/or completed any
Yes No
rehabilitation since your conviction? If Yes, explain.

2014 Kelly Services, Inc. An Equal Opportunity Employer e2382 R3/14

Page 4 of 11
 ADDITIONAL OFFENSE(S) SHEET
If convicted of more than one offense, complete one of these sheets for each additional offense upon which you were convicted.

Offense # 4
1. What is the offense for which you were convicted?
2. What is the date of conviction? / /
3. Indicate the type of offense. Felony Misdemeanor
4. Provide the facts and circumstances of each offense, including what happened and where (county and state) it
happened. If additional space is needed, please use extra paper.

5. Were you a juvenile when you committed the offense? Yes No

6. Did you act alone when committing the offense? Yes No
7. What was your sentence? If time was served in prison, indicate the sentence, how much time you served, and the
name and location of the prison facility.

8. Are you currently subject to any sentencing restrictions?

If Yes, explain and indicate if you are currently on probation, living in a half-way Yes No
house, on a tether, or restricted from engaging in specific activities.

9. Are you currently on probation/parole? If yes, complete the following: Yes No

Probation/Parole Officers Name: _______________________________
Phone Number: ___ / __ ___ / ____

10. Have you received recognition for good conduct and/or completed any
Yes No
rehabilitation since your conviction? If Yes, explain.

2014 Kelly Services, Inc. An Equal Opportunity Employer e2382 R3/14

Page 5 of 11
 ADDITIONAL OFFENSE(S) SHEET
If convicted of more than one offense, complete one of these sheets for each additional offense upon which you were convicted.

Offense # 5
1. What is the offense for which you were convicted?
2. What is the date of conviction? / /
3. Indicate the type of offense. Felony Misdemeanor
4. Provide the facts and circumstances of each offense, including what happened and where (county and state) it
happened. If additional space is needed, please use extra paper.

5. Were you a juvenile when you committed the offense? Yes No

6. Did you act alone when committing the offense? Yes No
7. What was your sentence? If time was served in prison, indicate the sentence, how much time you served, and the
name and location of the prison facility.

8. Are you currently subject to any sentencing restrictions?

If Yes, explain and indicate if you are currently on probation, living in a half-way Yes No
house, on a tether, or restricted from engaging in specific activities.

9. Are you currently on probation/parole? If yes, complete the following: Yes No

Probation/Parole Officers Name: _______________________________
Phone Number: ___ / __ ___ / ____

10. Have you received recognition for good conduct and/or completed any
Yes No
rehabilitation since your conviction? If Yes, explain.

2014 Kelly Services, Inc. An Equal Opportunity Employer e2382 R3/14

Page 6 of 11
 ADDITIONAL OFFENSE(S) SHEET
If convicted of more than one offense, complete one of these sheets for each additional offense upon which you were convicted.

Offense # 6
1. What is the offense for which you were convicted?
2. What is the date of conviction? / /
3. Indicate the type of offense. Felony Misdemeanor
4. Provide the facts and circumstances of each offense, including what happened and where (county and state) it
happened. If additional space is needed, please use extra paper.

5. Were you a juvenile when you committed the offense? Yes No

6. Did you act alone when committing the offense? Yes No
7. What was your sentence? If time was served in prison, indicate the sentence, how much time you served, and the
name and location of the prison facility.

8. Are you currently subject to any sentencing restrictions?

If Yes, explain and indicate if you are currently on probation, living in a half-way Yes No
house, on a tether, or restricted from engaging in specific activities.

9. Are you currently on probation/parole? If yes, complete the following: Yes No

Probation/Parole Officers Name: _______________________________
Phone Number: ___ / __ ___ / ____

10. Have you received recognition for good conduct and/or completed any
Yes No
rehabilitation since your conviction? If Yes, explain.

2014 Kelly Services, Inc. An Equal Opportunity Employer e2382 R3/14

Page 7 of 11
 ADDITIONAL OFFENSE(S) SHEET
If convicted of more than one offense, complete one of these sheets for each additional offense upon which you were convicted.

Offense # 7
1. What is the offense for which you were convicted?
2. What is the date of conviction? / /
3. Indicate the type of offense. Felony Misdemeanor
4. Provide the facts and circumstances of each offense, including what happened and where (county and state) it
happened. If additional space is needed, please use extra paper.

5. Were you a juvenile when you committed the offense? Yes No

6. Did you act alone when committing the offense? Yes No
7. What was your sentence? If time was served in prison, indicate the sentence, how much time you served, and the
name and location of the prison facility.

8. Are you currently subject to any sentencing restrictions?

If Yes, explain and indicate if you are currently on probation, living in a half-way Yes No
house, on a tether, or restricted from engaging in specific activities.

9. Are you currently on probation/parole? If yes, complete the following: Yes No

Probation/Parole Officers Name: _______________________________
Phone Number: ___ / __ ___ / ____

10. Have you received recognition for good conduct and/or completed any
Yes No
rehabilitation since your conviction? If Yes, explain.

2014 Kelly Services, Inc. An Equal Opportunity Employer e2382 R3/14

Page 8 of 11
 ADDITIONAL OFFENSE(S) SHEET
If convicted of more than one offense, complete one of these sheets for each additional offense upon which you were convicted.

Offense # 8
1. What is the offense for which you were convicted?
2. What is the date of conviction? / /
3. Indicate the type of offense. Felony Misdemeanor
4. Provide the facts and circumstances of each offense, including what happened and where (county and state) it
happened. If additional space is needed, please use extra paper.

5. Were you a juvenile when you committed the offense? Yes No

6. Did you act alone when committing the offense? Yes No
7. What was your sentence? If time was served in prison, indicate the sentence, how much time you served, and the
name and location of the prison facility.

8. Are you currently subject to any sentencing restrictions?

If Yes, explain and indicate if you are currently on probation, living in a half-way Yes No
house, on a tether, or restricted from engaging in specific activities.

9. Are you currently on probation/parole? If yes, complete the following: Yes No

Probation/Parole Officers Name: _______________________________
Phone Number: ___ / __ ___ / ____

10. Have you received recognition for good conduct and/or completed any
Yes No
rehabilitation since your conviction? If Yes, explain.

2014 Kelly Services, Inc. An Equal Opportunity Employer e2382 R3/14

Page 9 of 11
 ADDITIONAL OFFENSE(S) SHEET
If convicted of more than one offense, complete one of these sheets for each additional offense upon which you were convicted.

Offense # 9
1. What is the offense for which you were convicted?
2. What is the date of conviction? / /
3. Indicate the type of offense. Felony Misdemeanor
4. Provide the facts and circumstances of each offense, including what happened and where (county and state) it
happened. If additional space is needed, please use extra paper.

5. Were you a juvenile when you committed the offense? Yes No

6. Did you act alone when committing the offense? Yes No
7. What was your sentence? If time was served in prison, indicate the sentence, how much time you served, and the
name and location of the prison facility.

8. Are you currently subject to any sentencing restrictions?

If Yes, explain and indicate if you are currently on probation, living in a half-way Yes No
house, on a tether, or restricted from engaging in specific activities.

9. Are you currently on probation/parole? If yes, complete the following: Yes No

Probation/Parole Officers Name: _______________________________
Phone Number: ___ / __ ___ / ____

10. Have you received recognition for good conduct and/or completed any
Yes No
rehabilitation since your conviction? If Yes, explain.

2014 Kelly Services, Inc. An Equal Opportunity Employer e2382 R3/14

Page 10 of 11
 ADDITIONAL OFFENSE(S) SHEET
If convicted of more than one offense, complete one of these sheets for each additional offense upon which you were convicted.

Offense # 10
1. What is the offense for which you were convicted?
2. What is the date of conviction? / /
3. Indicate the type of offense. Felony Misdemeanor
4. Provide the facts and circumstances of each offense, including what happened and where (county and state) it
happened. If additional space is needed, please use extra paper.

5. Were you a juvenile when you committed the offense? Yes No

6. Did you act alone when committing the offense? Yes No
7. What was your sentence? If time was served in prison, indicate the sentence, how much time you served, and the
name and location of the prison facility.

8. Are you currently subject to any sentencing restrictions?

If Yes, explain and indicate if you are currently on probation, living in a half-way Yes No
house, on a tether, or restricted from engaging in specific activities.

9. Are you currently on probation/parole? If yes, complete the following: Yes No

Probation/Parole Officers Name: _______________________________
Phone Number: ___ / __ ___ / ____

10. Have you received recognition for good conduct and/or completed any
Yes No
rehabilitation since your conviction? If Yes, explain.

2014 Kelly Services, Inc. An Equal Opportunity Employer e2382 R3/14

Page 11 of 11