D.
_________________________________________________
Amount Owing $ ________________
Name of Business
___________________________________________________________________________________
Street Address
City and State
E.
_________________________________________________
Amount Owing $ ________________
Name of Business
___________________________________________________________________________________
Street Address
City and State
F.
_________________________________________________
Amount Owing $ ________________
Name of Business
___________________________________________________________________________________
Street Address
City and State
WORK HISTORY
26. Have you ever been denied employment by a law enforcement agency, corrections agency, or security
agency which required certification or licensure from any Commission, Board or Agency after a conditional
offer of employment was made?
Yes
No
If yes, list agency name and give details: _________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
27. Have you ever held a position in any capacity which required certification or licensure from any Commission, Board
or Agency established to certify or license that position? (Note: List any such Commission, Board, or Agency,
whether in or out of North Carolina.)
Yes
No
27a.
If yes, was such certification or license ever suspended, revoked, or any sanctions taken against it by the
issuing authority?
Yes
No
27b.
If such certification or license was ever suspended, revoked, or any sanctions taken against it by the
issuing authority, please list the agency’s name taking the action against the certification or license, date
of the action, reason for the action, and the period of time for the suspension, revocation, or sanction.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
F-3(LE) Rev. 12.2.13
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