Fillable Criminal History Questionnaire New Jersey Ofce of the (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Criminal History Questionnaire New Jersey Ofce of the (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Cemetery Board
124 Halsey Street, 6th Floor, P.O. Box 45036
Newark, New Jersey 07101
(973) 504-6553
Criminal History Questionnaire
Information to be provided by all salesperson applicants
who have been convicted of a criminal offense
Nameofapplicant(pleaseprint):____________________________________________________________________________
TheBoardconsidersonlyconvictionsindecidingwhethertoapprovelicenseapplications.Therefore,if you have never been
convicted of a criminal offense, you may disregard this form.However,ifyouhavebeenconvicted(thatis,iftheanswer
toquestion8onthelicenseapplicationformis“Yes”),youmustcompletethisformandsubmitcopiesofanydocumentations
pertainingtoeachconviction,andtothearrestandindictmentinconnectionwitheachconviction.Useaseparateformforeach
convictionorrelatedsetofconvictions.Ifyouneedadditionalforms,youmaycopythisform,ortheBoardwillsupplyyouwith
additionalcopies.Notethateachcountofanindictmentconstitutesaseparateoffense.Whenwehavereceivedthisinformation,
wewillresumeprocessingyourapplication.
1. Wheredidtheincidentoccurwhichgaverisetothearrest(cityandstate)?_____________________________________________
2. Whendidtheincidentoccurwhichgaverisetothearrest?__________________________________________________________
3. Whatwasthedateofthearrest?_________________________________________________
4. Whatwasthedateoftheindictment?_____________________________________________
5. Whatwasthedateoftheconviction?_____________________________________________
6. Whatcourthadjurisdiction?____________________________________________________
7. Describethenatureandseriousnessofthecrime.Indicatethedegreeofthecrime(rst,second,third,etc.)ifunderNewJerseylaw,
oritsequivalentifunderthelawofanotherjurisdiction.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
8. Whatwasyourageatthetimeofthecrime?___________________
9. Whatwerethecircumstancessurroundingthecrime?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
10. Describeanysocialconditionswhichmayhavecontributedtothecrime?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
11. Wasthecrimeisolatedorwasitarepeated?Ifitwasrepeated,howmanytimes?_______________________________________
12. Wastheincarcerationimposedinthesentence?Ifso,wasthesentencesuspendedorprobationgranted?Howmuchofthetermof
incarcerationdidyouserve?Wasparolegranted?Pleasedescribe:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
13. Wasaneimposedinthesentence?Pleasedescribewasitpaidorsuspended:
_________________________________________________________________________________________________________
14. Setforthanyothertermsofthesentence.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
15. Ifyouwereparoled,orifyouhaveservedorarestillservingprobation,submitastatementfromyourparoleorprobationofcer,
concerningyourrehabilitation.
16. Submitanyevidenceofrehabilitationincluding,butnotlimitedto,thefollowing:
(a) Evidenceofgoodconductwhileinprisonorinthecommunity;
(b) Evidenceofcounselingorpsychiatrictreatmentreceived;
(c) Evidenceoftheacquisitionofadditionalacademicorvocationalschooling;
(d) Evidence of successful participation in correctional work-release programs, recommendation of persons who have,
orhavehad,youundertheirsupervision;and
(e) Arehabilitatedoffender’scerticate.
Signatureofapplicant:_________________________________________________Date:__________________________________
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Criminal History Questionnaire New Jersey Ofce of the (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 14 August 2020

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