Free Print File - Michigan

BCS/LCE-020 (3/09)

BOARD OFFICE USE ONLY
Process Refer to Enforcement Date: By:

Michigan Department of Energy, Labor & Economic Growth Bureau of Commercial Services Licensing Division P.O. Box 30018, Lansing, MI 48909 517-241-9288; Fax 517-373-3085

REQUEST FOR CONVICTION HISTORY
Applicant's Name (Last, First, Middle) Date of Birth

Print

Clear

Social Security Number

Mailing Address (Number and Street)

City

State

Zip Code

Occupation:

License Type:

The following information is required in conjunction with your application for licensure/registration. In accordance with The Former Offenders Act, 1974 P.A. 381, as amended, this is to provide you with an opportunity to explain your affirmative response to the question(s) on your application which asked if you had been convicted of a felony or misdemeanor. REPORT ALL CONVICTIONS. Use the back of this form or an attachment if you wish to provide additional information. If you are unsure of exact details, respond to the best of your knowledge. Failure to provide the information may result in the denial of your application.
1. Your name when convicted. 2. Indicate ALL crimes for which you were charged and convicted.

3. Name and address of sentencing court(s):

4. Date(s) of conviction(s) and sentence(s):

5. Check Yes or No to the following: A. Current Inmate? Yes No

B. Current on Probation/Parole?

Yes

No

C. Name, address and telephone number of correctional facility, probation officer, or parole office, if applicable:

6. Release date from custody, probation or parole:

7. Rehabilitation programs enrolled in or completed:

I hereby certify that the statements and facts provided are true and accurate to the best of my knowledge. Signature Date

DELEG is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.