Li-400 Disclosure Document Checklist Page 2
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2SECTION 1:
APPLICANT / LICENSEE INFORMATION
NAME (Last, First MI)
License / Registration # (if any)
Email
Phone
SECTION 2:
CRIMINAL OFFENSES – provide the following CERTIFIED Documents as they apply
Judgment / Deferral
Order of Dismissal from Probation
DO NOT REMOVE STAPLES FROM
Order Expunging, Dismissing, or Vacating a Conviction and restoring civil rights
CERTIFIED DOCUMENTS AS IT
Record has been purged, destroyed or is no longer available
NULLIFIES THE CERTIFICATION
– attach an official statement from the court or agency stating the reason that
the document is not longer available
Additional documents as outlined in Section 5
SECTION 3:
CIVIL ACTIONS – provide the following CERTIFIED Documents as they apply
Complaint and/or Amended Complaint
DO NOT REMOVE STAPLES FROM
Judgment
CERTIFIED DOCUMENTS AS IT
Satisfaction of Judgment
NULLIFIES THE CERTIFICATION
Additional documents as outlined in Section 5
SECTION 4:
DISCIPLINARY ACTIONS – provide the following CERTIFIED Documents
Final Order of Administrative
Consent or Settlement Agreement
DO NOT REMOVE STAPLES FROM
Order of Payment from a Recovery Fund
CERTIFIED DOCUMENTS AS IT
License History from any other agency where a professional license is/was
NULLIFIES THE CERTIFICATION
held involving any type of action on the license in the last 5 years from
disclosure
Additional documents as outlined in Section 5
SECTION 5:
ADDITIONAL DOCUMENTS
Submit a signed, dated and detailed statement written by you- including the following (if it applies to your conviction,
judgment, restriction, disciplinary action, civil judgment, or Recovery Fund Payment).
Detail of
Conviction
Judgment,
Classes-
Arresting Agency
Court
offense-
Date-
Sentence, or
Time Served &
Probation Details-
Name-
Name &
Type of Offense-
total fines-
Termination of Probation-
-
Location
Three written, signed and dated references from individuals, 18 years or older and not related by blood or marriage,
that have known the applicant for more than one year. Each letter cannot be dated more than one year from the date
of the disclosure/application date.
10 Year work history including the employer’s name and address, supervisor’s name and telephone number, dates of
employment and position held. Include all periods of unemployment.
Legal Presence Documentation – if not previously provided. Visit
for a list of acceptable documents.
Fingerprint Clearance Card (FCC) – application can be obtained through the Department of Public Safety (DPS).
DPS contact information:
Phone: 602.223.2279
Fax request to: 602.223.2947
The ADRE requires that a FCC application be submitted through DPS within 10 business days of disclosure.
FAILURE TO PROVIDE THE ADRE WITH THE REQUIRED DOCUMENTATION BY THE REQUIRED DATE
MAY DELAY AND OR AFFECT LICENSURE
ENSURE THAT ALL REQUIRED DOCUMENTS ON CHECKLIST ARE PROVIDED TO ADRE
LI-213 REV 11/2011
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