7. Have you ever been convicted of a criminal offense? List all criminal offenses of which the applicant has been convicted,
including the date and place of each conviction and the name under which he or she was convicted, if other than the name
on the application. (Minor trafc offenses such as parking or speeding violations need not be listed; however, motor vehicle
offenses such as driving while impaired or intoxicated must be disclosed.) Yes No
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a
complete
explanation. (Attach additional sheets of paper to this application.)
8. Do you currently hold, or have you ever held, a professional or occupational license or certicate of any kind in New Jersey,
any otherstate,the District of Columbia or in any other jurisdiction? Yes No
If “Yes,” for each license or certicate held, provide the date(s) held and the number(s). If the license or certicate was issued under
a different name, please provide that name.
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
9. Have you ever been disciplined or denied a professional or occupational license or certicate of any kind in New Jersey,
any other state, the District of Columbia or in any other jurisdiction? Yes No
10. Have you ever had a professional or occupational license or certicate of any type suspended, revoked or surrendered in
New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
11. Have you ever been cited for disciplinary reasons or denied a professional or occupational license or certicate of any kind
in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
12. Have you ever been named as a defendant in any litigation related to the practice of locksmithing or other professional or
occupational practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
13. Are you aware of any investigation pending against a professional or occupational license or certicate issued to you by a
certication board in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
14. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any
other jurisdiction? Yes No
15. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional or
occupational group related to the practice of locksmithing or other professional or occupational practice in New Jersey, any
other state, the District of Columbia or in any other jurisdiction? Yes No
If the answer to any of the above questions, numbers 9 through 15, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.