| Check YES to all that apply | Check NO to all that do NOT apply | Crime | Self | Other household member | Date of conviction, guilty plea, no contest plea or pending charges | Sentence | ||
|---|---|---|---|---|---|---|---|---|
| YES☐ | NO☐ | 18 Pa.C.S. § 6320 (relating to sexual exploitation of children) | undefined | NO | undefined | undefined | ||
| YES☐ | NO☐ | 23 Pa.C.S. § 6114 (relating to contempt for violation of protection order or agreement) | undefined | NO | undefined | undefined | ||
| YES☐ | NO☐ | Driving under the influence of drugs or alcohol | undefined | undefined | undefined | undefined | ||
| YES☐ | NO☐ | Manufacture, sale, delivery, holding, offering for sale or possession of any controlled substance or other drug or device | undefined | NO | undefined | undefined | ||
| YES☐ | NO☐ | 18 Pa.C.S. Ch. 30 (relating to human trafficking) | undefined | undefined | undefined | undefined | ||
| YES☐ | NO☐ | 18 Pa.C.S. § 5902(b.1) (relating to prostitution and related offenses) | undefined | NO | undefined | undefined |