Personal History Disclosure Form printable pdf download

Personal History Disclosure Form

AGENCY OF NATURAL RESOURCES

State of Vermont

DEPARTMENT OF ENVIRONMENTAL CONSERVATION

Waste Management and Prevention Division

One National Life Drive – Davis 1

Montpelier VT 05620-3704

(802) 522-5949

cheryl.hamilton@vermont.gov

PERSONAL HISTORY DISCLOSURE FORM

Applicant: ________________________________________________________________

Last

First

Middle

Maiden or Alias Names:______________________________________________________

Place of Birth: ______________________________________________________________

City/Town

State

County

Date of Birth: _______________________________________

Month

Day

Year

Section 1 – Disclosure of Criminal Record of Convictions (please circle yes or no)

Have yo

Have you ever been convicted of robbery, as t

Have you ever been convicted of extortion, as that offense is defined in 13 V.S.A. Section

Have you ever been convicted of larceny and embezzlement, as that offense is defined in 13 V.S.A.

Have you ever been convicted of forgery and fraud, as that offense is defined in 13 V.S.A. Chapters 43,

47, and 49 and 9 V.S.A. Chapters 63, 67, 71, 105, and 1

Regional Offices – Barre/Essex Jct./Rutland/Springfield/St. Johnsbury

Personal History Disclosure Form