Fillable Criminal History Form (State of Nevada, Department of Information Technology)

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Criminal History Form (State of Nevada, Department of Information Technology)

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The Criminal History Form (State of Nevada, Department of Information Technology) form is 1 page long and contains:

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Country of origin: US
File type: PDF

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BROWSE STATE OF NEVADA, DEPARTMENT OF INFORMATION TECHNOLOGY (NV) FORMS

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STATE OF NEVADA
FUNERAL AND CEMETERY SERVICES BOARD
3740 Lakeside Drive, Suite 201, Reno, Nevada 89509
Phone (775) 825-5535 * Fax (775) 507-4102
Email: nvfuneralboard@fb.nv.gov * Website: http://funeral.nv.gov/
Nevada Funeral Board Criminal History Form Rev. 8/13/2019
Criminal History Form
Information
This form is used in conjunction with various license application forms to provide details concerning criminal history.
This form must be completed if applicant for any license has a criminal history. Each “item” on this form should indicate
a separate criminal prosecution in which you plead guilty, were found guilty, or plead nolo contendere (no contest). You
will need to fill out a copy of this form for each prosecution (copy as needed). A copy of the police report and/or other
legal documents related to the criminal charge must be attached to this criminal history form for each crime
charged.
Personal Information
Full Legal Name:
Item (Police report and or other legal documents related to the criminal charge must be attached)
Year charges were filed against you:
Court Location:
Case Number:
Crime Charged:
Case Outcome:
☐ Pled Guilty
☐ Pled no contest
Date on which you pled guilty, found guilty or pled no contest:
Penalty Imposed:
Type of Conviction
☐ Category A or B Felony
☐ Gross Misdemeanor
☐ Other:
☐ Category C, D or E Felony
☐ Misdemeanor
Have all sanctions imposed been satisfied?
☐ Yes
☐ No
Have you attached the police report and/or legal documents related to the criminal
charge(s)?
☐ Yes
☐ No
Do you have any other criminal record items to disclose?
☐ Yes
☐ No
If yes, each item requires another copy of this form.
Declaration of Applicant
I hereby declare under penalty of perjury, that all of the information supplied herein is to the best of my knowledge true,
accurate and complete and I have not withheld, misrepresented, or falsely stated any information contained herein.
Signature of Applicant
Date
Print Name
CLEAR
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Criminal History Form (State of Nevada, Department of Information Technology)

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Completed 27 October 2020

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