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