Dbpr Form Abt-6012 - Examination Application Page 2

SECTION 3 - CORPORATE FELONY CONVICTION

Trade Name (D/B/A)

Has the applicant corporation been convicted of a felony in this state, any other state, or by the United

States in the last 15 years?

Yes

If the answer is “Yes,” please list all details including the date of conviction, the crime for which the

corporation was convicted, and the city, county, state and court where the conviction took place.

SECTION 4 - DISCLOSURE OF INTERESTED PARTIES

Note: Failure to disclose an interest, direct or indirect, could result in denial, suspension and/or

revocation of your license.

List below the names of all persons connected, directly or indirectly, in the business for which the license is

sought. Attach extra sheets if necessary.

Trade Name (D/B/A)

NAME

OFFICE (if corporation)

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Parent category: Legal