Disciplinary Action Questionnaire - Texas Department Of Licensing And Regulation printable pdf download

Disciplinary Action Questionnaire - Texas Department Of Licensing And Regulation

TEXAS DEPARTMENT OF LICENSING AND REGULATION

PO Box 12157 • Austin, Texas 78711 • (512) 463‐6599 • ( 800) 803‐9202 • Fax (512) 475‐2871

DISCIPLINARY ACTION QUESTIONNAIRE

If you have had an occupational license revoked, suspended, probated or denied in any state, county or

municipality, the Department must review your disciplinary action history to determine if you are eligible

to obtain a license. You should provide exact details when completing this form.

Questions regarding this form may be addressed to the TDLR Enforcement Division at (512)539‐5600. Please

mail this form, along with the appropriate application and fee, to the address above. If you need to email it,

please send it to CHQ@tdlr.texas.gov and also provide the type of license you are applying for with TDLR.

Type of License you are applying for: ______________________________

(Ex: Barber, Cosmetologist, Electrician, Towing, etc.)

Name: _________________________________________________Social Security Number: ________________

Last

First

Middle

Address: ___________________________________City: ______________ State: _______ Zip Code: _________

Phone: _____________________________ E‐mail*: _______________________________________________

PART ONE: License Revoked, Suspended or Probated

If you have had one, or more, occupational licenses revoked, suspended or probated, please complete this

section. Please provide the requested information as to each revocation, suspension or probation. Attach

additional pages if necessary.

Type of occupational license:

Full name on the license:

___________

License number:

Date the license was issued: ___________________________________

Name and address of the agency that issued the license:

Name and address of the agency that imposed sanctions, if different from the issuing agency:

Please describe the exact type of sanction received: __________________________________________________

(Example: revocation, suspension, probation, etc.)

Date the sanction was imposed: _______________________________

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Rev 02/2013 DAQ01

Disciplinary Action Questionnaire - Texas Department Of Licensing And Regulation