Explanation Of Incident - Arizona Department Of Education

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E
I
XPLANATION OF
NCIDENT
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RIZONA
EPARTMENT OF
DUCATION
ERTIFICATION
NIT
Mailing Address: P.O. Box 6490, Phoenix, AZ 85005-6490
Telephone: (602) 542-4367
If you have answered "Yes" to a Background Question on your application because of an arrest or felony conviction
(question 3, 4, or 5 a-bb), please provide the following information. Note: If there was more than one incident, provide a
separate explanation form for each incident.
Social Security Number:
_________-______-____________
Full Legal Name: ___________________________________________________________________________
Last
First
Middle
Date of Arrest: ____________ Arresting City: _________________________ Arresting State: ____________
Name of offense (Reason of the arrest): _________________________________________________________
Description of the circumstances of the arrest: (If more space is needed, continue on back.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
______________________________________________________________________________
Disposition of the case:
___________________________________________________________________________________________
Mitigating factors pertaining to the arrest:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
______________________________________________________________________________
Sentencing information if convicted:
___________________________________________________________________________________________
______________________________________________________________________________
Signature: ________________________________________________________ Date: ____________________
** R
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EQUIREMENTS MAY BE SUBJECT TO CHANGE AND ARE FULLY REFERENCED IN THE
RIZONA
EVISED
TATUTES AND
DMINISTRATIVE
ODE
Version 2.1 (Rev.7-30-2016)
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