Background History Form Page 2
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35. OTHER OCCUPATIONAL/PROFESSIONAL LICENSES:
Issuing State:
Type of License:
Date Issued:
Status:
Active
Inactive
Expired
Other
Action Taken on License (if applicable):
Revoked
Surrendered
Suspended
Terminated
Other
Effective Date of Action:
Explanation of circumstances leading to any action taken:
Documentation Needed: Submit license history signed by state licensing agency.
6. OUTSTANDING JUDGMENTS
Status:
Final Judgment
Judgment Appealed
Explanation of circumstances leading to judgment and any payment plan for outstanding judgment:
Documentation Needed: Submit copies of all petitions, responses and judgments.
7. CRIMINAL HISTORY
Style and Cause Number:
Initial Charge:
Misdemeanor
Felony
Ultimate Charge:
Misdemeanor
Felony
Title of Court:
County of Court:
Plea:
Guilty
Not Guilty
Nolo Contendere
Other
Date crime committed
Date sentenced:
Disposition (check all that apply):
Adjudicated Guilty
Adjudicated Not Guilty
Probation
term
Deferred Adjudication
Deferred Prosecution
Shock Probation
Incarceration:
Community Service Ordered
Restitution Ordered
Explanation of circumstances leading to criminal charges:
Regarding parole, community supervision or probation:
Yes
No
Have you been released from any of the above:
Have you ever violated the terms of any of the above:
Date of release:
Yes
No
Page 2 of 3
BH-2 (Background History Form) (06/20/2016)
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