Criminal Conviction Disclosure

In responding to the question below, do not disclose the existence of any conviction which has been annulled, erased, sealed, expunged, or otherwise
eradicated by state or court order. As an Express Employment Professionals ("Express") policy, associates are not required to disclose felony or
misdemeanor convictions older than seven (7) years from the date this form is executed (except as indicated below in California and
Massachusetts).

Please read any applicable state notices before answering the criminal conviction questions below.

CA Associates: Associates are not required to disclose misdemeanor convictions involving marijuana or controlled substances that are more than
two years old, and misdemeanor convictions for which probation has been successfully completed or discharged and that have been judicially
dismissed.
CT Associates: Associates are not required to disclose any conviction that has been erased under CT General Statute § 46(b) - 146, 54-76(o) or
54-142(a). Criminal records subject to erasure are records pertaining to a finding of delinquency or that a child was a member of a family
with service needs, an adjudication as a youthful offender, a criminal charge for which the person has been found not guilty, or a conviction
for which the person received an absolute pardon. Any person whose criminal records have been erased shall be deemed to have never been
arrested with respect to the proceedings so erased.
GA Associates: Associates may exclude convictions discharged under Georgia's First Offender Programs.
HI Associates: Associates may exclude misdemeanor convictions older than five years (excluding periods of incarceration).
MA Associates: Under Massachusetts law, after the application stage, associates may omit from disclosing a first conviction for drunkenness,
simple assault, speeding, affray, minor traffic violations or disturbances of the peace. Associates are also only required to disclose
misdemeanor convictions occurring within three (3) years preceding the date of this form.
An applicant for employment with a record expunged pursuant to section 100F, section 100G, section 100H or section 100K of chapter 276 of the
General Laws may answer ‘no record’ with respect to an inquiry herein relative to prior arrests, adjudications, or juvenile and/or criminal court
appearances or convictions.
NY Associates: Associates may exclude an adjudication as a youthful offender.
OH Associates: Associates with a conviction for a minor misdemeanor violation involving marijuana does not constitute a criminal record and
does not need to be reported by the person so convicted in responding to the questions on this form.
VA Associates: Associates are not required to disclose information concerning any arrest, criminal charge, or conviction for marijuana possession.

Have you ever pled guilty, no contest, or been convicted of a criminal offense that has not been sealed, erased, expunged, or annulled by a court or
for which you have not been pardoned?

‰ Yes ‰
✔ No

(A criminal conviction does not necessarily disqualify you from employment but may limit the assignments we can send you on. Convictions will be
considered based on the time and nature of the offense as it relates to your job duties when you are considered for an assignment.)

Explain below, including the nature of the offense, any money or property value associated with the offense, when the offense occurred, the sentence
imposed, and any other details you would like to explain.

Name: Maria Elena Mariscal Rocha

(Please print full name)

Social Security Number: 633 - 12 - 4536

I hereby certify, under penalty of perjury, that all statements, answers, and representations on this form are true, complete, and accurate.

Signature: Maria Elena Mariscal Rocha Date: 4/12/2021

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