Statement Regarding Criminal Plea Conviction -CSLB

Statement Regarding Criminal Plea/Conviction

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APPLICANT AND PLEA/CONVICTION INFORMATION

* Required Entry

*APPLICANT NAME:

*ARRESTING AGENCY:

*PLEA/CONVICTION DATE:

*COURT CASE/DOCKET NUMBER:

*PLEA/CONVICTION LEVEL: *PLEA/CONVICTION LEVEL:

Misdemeanor Felony

*COURT NAME AND LOCATION:

*VIOLATION CODE(S):

SENTENCE INFORMATION

* Required Entry

*SENTENCE IMPOSED: Please describe any punishment imposed by the court.

*WERE YOU INCARCERATED?

Yes No

*INCARCERATION DATE:

*RELEASE DATE:

*Incarceration Date must be before Release Date

PROBATION/PAROLE INFORMATION

* Required Entry

*WERE YOU PUT ON PROBATION OR PAROLE? Yes No

*PROBATION/PAROLE DATE:

*COMPLETION DATE:

Probation/Parole Date must be before Completion Date

*TERMS AND CONDITIONS OF PROBATION/PAROLE:

*PROBATION OFFICER/PAROLE AGENT NAME & PHONE NUMBER:

*HAVE THE FINES BEEN PAID IN FULL? Yes No N/A

*HAS THE RESTITUTION BEEN PAID IN FULL? Yes No N/A

CRIME AND REHABILITATION INFORMATION

* Required Entry

*DETAILS OF CRIME: Please provide details of this crime, including a complete description of the facts and circumstances that led to your plea/conviction. You should include who participated in the crime; who the victim was; what losses were suffered; and when, where, and how the crime occurred.

*REHABILITATION EFFORTS: What positive changes have you made in your life since this conviction? Please attach documentation to support any rehabilitation efforts.

Review and Edit

Please Review the Following Information

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Completion Instructions

NOTICE: This document is not submitted to or saved by CSLB. You must either print it now, save it to your computer, or email it to your email address to print and mail at a later time.

Mail your document(s) along with the application to:

Contractors State License Board
P. O. Box 26000
Sacramento, CA 95826

PDF

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Statement Regarding Criminal Plea/Conviction