Criminal History Questionnaire Form printable pdf download

EXAS

EPARTMENT OF

ICENSING AND

EGULATION

Enforcement Division

P.O. Box 12157 • Austin, Texas 78711 • (512) 539‐5600 • (800) 803‐9202 • fax (512) 539‐5698

Web site:

CRIMINAL HISTORY QUESTIONNAIRE

The Department must review your criminal history to determine if you are eligible to obtain or

retain a license. Depending on your criminal history, review can take from one to six weeks to

complete. The assigned Department representative will contact you if necessary.

Complete this form if you have been convicted of a felony or misdemeanor, other than a minor

traffic violation, or pleaded guilty or no contest (resulting in a deferred adjudication) to any

criminal offense. Be specific and provide exact details. Attach a separate form for each crime.

Questions regarding this form may be addressed to the Department’s Enforcement Division at

enforcement@license.state.tx.us, or by phone at (512)539‐5600.

Name: First _______________ Middle____________ Last______________ SSN: ‐ ‐____

Address: ___________________________City: ___________ State: _______ Zip Code: ______

Phone: ________________ DOB:__________ E‐mail: _______________________________

County where convicted: __________________ Court where convicted: _________________

(example: Travis County)

(example: 300

District Court)

Date crime committed: __________________ Date of conviction: _______________________

Exact crime you were convicted of: _________________________________________________

What exactly did you do (crime) and why?

________

(If you need more space to write, attach additional sheets)

_____________________________________________________________________________________

Sentence or action imposed by the court: (example: six months in Travis County Jail) _________

______________________________________________________________________________

For renewals, did this conviction occur since your license was last issued: _____ yes _____ no

Are you currently on probation? ___ yes ___ no Are you currently on parole? ___ yes ___ no

If so, list your reporting officer’s name: __________________ phone number: ______________

Intentional failure to provide full and accurate information could result in delay of issuance or

denial of your license.

Signature:______________________________________ Date: _______________________

Criminal History Questionnaire Form