Form Fs 512 Siq - Statement Of Identity And Questionnaire (Page 3 of 5) in pdf

Form Fs 512 Siq - Statement Of Identity And Questionnaire Page 3

Insert Full Name

Insert Licensee

of Individual: _______________________

(Company Name):

License Period

License

Type of License/Business

Name and Address of Licensing Entity

From:

To:

Number

Attach separate schedule if space is not adequate.

b. Have you ever been refused a license to engage in any business in this state or any other state, or has

any such license ever been suspended, revoked, or surrendered subject to a settlement, or any other

similar action?

Yes

If the answer is "Yes", give details:

Attach a copy of any settlement.

Have you ever been convicted of or pleaded nolo contendere to a misdemeanor or felony other than minor

traffic citations that do not constitute a misdemeanor or felony offense?

"Convicted" includes a verdict of guilty by judge or jury, a plea of guilty or of nolo contendere or a

forfeiture of bail. All convictions must be disclosed even if the plea or verdict was thereafter set aside

and the charges against you dismissed or expunged or if you have been pardoned. Convictions

occurring while you were a minor must be disclosed unless the record of conviction has been sealed

under Section 1203.45 of the California Penal Code or Section 781 of the California Welfare and

Institution Code.

Yes

If the answer is "Yes", give details:

Attach a copy of any order, judgment or decree. If a conviction was entered under Section 23152(a) of the Vehicle

Code, attach a written declaration stating whether drugs were involved.

Have you ever been a defendant in a civil court action other than divorce, condemnation or personal

injury?

Yes

If the answer is "Yes", please complete the following:

Date of suit

Location of court

Nature of suit

Attach a copy of any order, judgment or decree.

FS 512 SIQ (Rev. 9/07)

Form Fs 512 Siq - Statement Of Identity And Questionnaire Page 3