RECORD OF CONVICTION
(If more than two convictions attach required information on plain bond.)
The penal code must be submitted or this document can not be processed.
Date of Conviction:____________________________________ Penal Code No. _________________________
Arresting Authority: __________________________________ City and State:___________________________
Nature Of Offense:_____________________________________________________________________________
_____________________________________________________________________________________________
Sentence and/or Fine Imposed: ___________________________________________________________________
_____________________________________________________________________________________________
Remarks: ____________________________________________________________________________________
_____________________________________________________________________________________________
Date of Conviction:____________________________________ Penal Code No. _________________________
Arresting Authority: __________________________________ City and State:___________________________
Nature Of Offense:_____________________________________________________________________________
_____________________________________________________________________________________________
Sentence and/or Fine Imposed: ___________________________________________________________________
_____________________________________________________________________________________________
Remarks: ____________________________________________________________________________________
_____________________________________________________________________________________________
I certify that I have listed all convictions.
Print Name _______________________ Signature ___________________________________ Date _________
This form must be returned to the ECC Human Resources Office prior to the closing date of the position for which
you are applying. Under the California Education Code, any person convicted under sections 87010, 87011
or 87405 are classified as ineligible for employment in any California community college district, unless
such person has a certificate of rehabilitation and has been rehabilitated for at least five years.
FORM ECC10
Rev. 4/05
ID # ____________