REPORT AND CERTIFICATION (under Act 24 of 2011)
Full Legal Name: Date of Birth: Any former names by which you have been identified:
By checking this box, I report that I have been arrested for or convicted of an offense or offenses enumerated under 24 P.S. §l-lll(e) ("Reportable Offense(s)"). See Instructions on Page 2 of this Form for a list of Reportable...
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