Disclosure Statement printable pdf download

Disclosure Statement

CONTRACTORS STATE LICENSE BOARD

STATE OF CALIFORNIA

9821 Business Park Drive, Sacramento, California 95827

Governor Edmund G. Brown Jr.

Mailing Address: P.O. Box 26000, Sacramento, CA 95826

800-321-CSLB (2752)

▪

Disclosure Statement Regarding Criminal Plea/Conviction

Please complete one form for each plea or conviction, regardless of when the crime was committed or whether it was dismissed or

expunged. All fields must be completed. FAILURE TO ACCURATELY REPORT ANY AND ALL DISCLOSABLE PLEAS/CONVICTIONS MAY BE

GROUNDS FOR THE DENIAL OF YOUR APPLICATION.

Applicant Name:

Arresting Agency:

Plea/Conviction Date:

Court Case/Docket Number:



Plea/Conviction Level:

Misdemeanor

Felony

Court Name and Location:

Violation Code(s):

Sentence Imposed:

Please describe any punishment imposed by the court.

Incarceration Date:

Release Date:

Probation/Parole Date:

Completion Date:

Terms and Conditions of Probation/Parole:

Probation Officer/Parole Agent Name & Phone Number:



Fines

Paid?

Yes

No Restitution

: $

Paid?

Yes

(amount)

Please provide details of this crime, including a complete description of the facts and circumstances that led to your conviction.

Details of Crime:

You should include who participated in the crime; who the victim was; what losses were suffered; and when, where, and how the

crime occurred.

What positive changes have you made in your life since this conviction? Please attach documentation to support any

Rehabilitation Efforts:

rehabilitation efforts.

*cbu-disclose*

FOR CSLB USE ONLY

13A‐45 (rev. 06/16)

Disclosure Statement

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