Application For Washington State Conditional Certificate Page 7
Download a blank fillable Application For Washington State Conditional Certificate in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Application For Washington State Conditional Certificate with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12Yes
No
10.
Have you ever been disciplined by a past or present employer because of allegations of misconduct?
11.
Are you currently or have you ever been the subject of any investigation or inquiry by an employer because of
allegations of misconduct?
SECTION III - CRIMINAL HISTORY
If you answer “yes” to any of the questions 1–5 (Section III), please provide the following:
A. On a separate sheet of paper state the following:
a.
A detailed statement including what occurred, the nature of the offense, charge or warrant.
b.
The name and address of the arresting agency.
c.
If a court was involved, the name and address of the court.
d.
The date of the arrest.
e.
The final disposition, if any.
B.
If a court was involved, provide a copy of the court docket (can be obtained at the court in which the charge[s] were filed).
C.
Provide a copy of the complete arresting officer’s report.
D.
If a court was involved, provide the sentence and judgment (can be obtained at the court in which the charge[s] were filed).
E.
If the arrest was driving related, provide a copy of a current and complete 5-year driving abstract.
NOTE: For questions 1, 2, 3, DO NOT include minor in possession (MIP)/minor in consumption (MIC) occurring more than 2 years
ago or driving under influence (DUI) occurring more than 5 years ago.
Yes
No
1.
In the last 10 years, have you ever been arrested for any crime or violation of the law? (Do NOT include Minor in
Possession [MIP]/Minor in Consumption [MIC] occurring more than 2 years ago or Driving Under Influence
[DUI/DWI] occurring more than 5 years ago.) (Note: For “yes” responses to 1, 2, 3, even if your case was
dismissed or your record was sealed you must answer this question in the affirmative.) You need not list traffic
violations for which a fine or forfeiture of less than $300 was imposed.
2.
In the last 10 years, have you ever been fingerprinted as a result of any arrest for any crime or violation of the law?
3.
In the last 10 years, have you ever been convicted of any crime or violation of any law? (Note: For the purpose of
this question “convicted” includes [1] all instances in which a plea of guilty or nolo contendere is the basis of
conviction, [2] all proceedings in which a sentence has been suspended or deferred, [3] or bail forfeiture.) You
need not list traffic violations or fines for which a fine or forfeiture of less than $300 was imposed.
4.
Have you ever been convicted of any felony crime?
Do you currently have any outstanding criminal charges or warrants of arrest pending against you? This would
5.
include Washington State, any other state, province, territory, and/or country.
6.
Have you ever been or are you presently under investigation in any jurisdiction for possible criminal charges? If
your answer is “yes,” identify agency and location (street address, city, state) and the circumstances or details
relating to the investigation on a separate piece of paper.
SECTION IV - FITNESS
If you answer “yes” to any question (Section IV), provide a written explanation on a separate sheet of paper:
Yes
No
1.
Have you ever exhibited any behavior or conduct which might negatively impact your ability to serve in a role which
requires a certificate, credential, or license?
2.
In the past 10 years, have you ever engaged in any conduct which resulted in the damage or destruction of
property? (For purposes of questions 2 and 3, property includes both real and personal property owned by you or
another. Do not list damages done as the result of an automobile accident.)
3.
In the last 10 years, have you ever threatened to damage or destroy property?
Have you ever engaged in any conduct which resulted in the physical injury or harm of any person(s)? (Do not list
4.
injury or harm caused as the result of duties performed due to a job assignment such as police officer, armed
forces member, or athlete.)
Have you ever threatened to do physical injury or harm to any person(s)? (Do not list threats issued as the result of
5.
duties performed due to a job assignment such as police officer, armed forces member, or athlete.)
FORM SPI/CERT 4020B (Rev. 9/15)
Page 2 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business