I certify under penalty of perjury that the above information is true and correct to the best of my
knowledge.
Signature
____________________________________________
Date
____________________
II. Instructions to Licensees:
If the person discloses a criminal conviction, review the person’s statement and discuss it with your
Licensing Program Analyst (LPA). Maintain this form in your facility personnel file and
send a copy
to your LPA.
In which state and city did you commit the offense?
When did this occur?
Tell us what happened. (Use additional sheets of paper if needed)
PRIVACY STATEMENT
Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code section 1798
et seq.), notice is given for the request of the Social Security Number (SSN) on this form. The California Department
of Justice uses a person’s SSN as an identifying number. The requested SSN is voluntary. Failure to provide the
SSN may delay the processing of this form and the criminal record check.
In order to be licensed, work at, or be present at, a licensed facility, the law requires that you complete a criminal
background check. (Health and Safety Code sections 1522, 1568.09, 1569.17 and 1596.871) The Department will
create a file concerning your criminal background check that will contain certain documents, including information that
you provide. You have the right to access certain records containing your personal information maintained by the
Department (Civil Code section 1798 et seq.). Under the California Public Records Act, the Department may have
to provide copies of some of the records in the file to members of the public who ask for them, including newspaper
and television reporters.
NOTE: IMPORTANT INFORMATION
The Department is required to tell people who ask, including the press, if someone in a licensed facility has a
criminal record exemption. The Department must also tell people who ask, the name of a licensed facility that has a
licensee, employee, resident, or other person with a criminal record exemption.
If you have any questions about this form, please contact your local licensing regional office.
What was the offense?
I. Instructions to Respondents:
If you have been convicted of a crime in California, another state or in federal court, provide
the following information:
(You need not disclose any marijuana-related offenses covered by the marijuana reform legislation codified at Health and Safety
Code sections 11361.5 and 11361.7.)
LIC 508 (3/11) REQUIRED FORM -- NO CHANGE PERMITTED PAGE 2 OF 2
