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d
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gna
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January 2021
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P
ar
t
II
:
C
r
imi
na
l
H
ist
ory D
is
c
l
o
s
ure
St
a
t
e
m
en
t:
P
ur
s
uan
t
t
o
l
eg
isl
a
ti
on,
titl
e 70 O.
S
. 1991, 3-104.1, every app
li
can
t
is
requ
i
red
t
o an
s
wer each of
t
he fo
ll
ow
i
ng que
sti
on
s:
1. Dur
i
ng
t
he preced
i
ng
t
en-year per
i
od, have you been conv
i
c
t
ed of a fe
l
ony?
……...................................................................................................................Ye
s
____ No ____
2. Dur
i
ng
t
he preced
i
ng
t
en-year per
i
od, have you been conv
i
c
t
ed of a cr
im
e
i
nvo
l
v
i
ng
m
ora
l
t
urp
it
ude?...........................................................................................................Ye
s
____ No ____
3. Have you ever been conv
i
c
t
ed
i
n Ok
l
aho
m
a, whe
t
her upon a verd
i
c
t
or p
l
ea of gu
ilt
y or upon a
p
l
ea of no
l
o con
t
endere (no con
t
e
st
), or rece
i
ved a
s
u
s
pended
s
en
t
ence for a cr
im
e or an a
tt
e
m
p
t
t
o co
mmit
a cr
im
e wh
i
ch
is
con
si
dered
s
exua
ll
y re
l
a
t
ed
i
n na
t
ure? ...Ye
s
____ No ____
4. Have you ever been conv
i
c
t
ed, rece
i
ved a
s
u
s
pended
s
en
t
ence, or rece
i
ved a deferred
j
udg
m
en
t
for a cr
im
e or a
tt
e
m
p
t
ed cr
im
e wh
i
ch wa
s
con
si
dered
s
exua
ll
y re
l
a
t
ed
i
n na
t
ure
i
n any
o
t
her
st
a
t
e or
j
ur
is
d
i
c
ti
on?...........................................................................Ye
s
____ No ____
5. Have you ever had adver
s
e ac
ti
on
t
aken aga
i
n
st
any educa
t
or cer
ti
f
i
ca
t
e or
li
cen
s
e
i
n
Ok
l
aho
m
a or any o
t
her
st
a
t
e or
j
ur
is
d
i
c
ti
on?......................................................Ye
s
____ No ____
6. I
s
any ac
ti
on now pend
i
ng aga
i
n
st
you for a
ll
eged
mis
conduc
t
i
n any
s
choo
l
d
ist
r
i
c
t
, cour
t
, or
any educa
t
or
li
cen
si
ng agency
i
n Ok
l
aho
m
a or any o
t
her
st
a
t
e
/j
ur
is
d
i
c
ti
on…... Ye
s
___ No ____
7. Do you curren
tl
y have any ou
tst
and
i
ng cr
imi
na
l
charge
s
or warran
ts
of arre
st
pend
i
ng aga
i
n
st
you
i
n Ok
l
aho
m
a or
i
n any o
t
her
st
a
t
e or
j
ur
is
d
i
c
ti
on?........................................Ye
s
____ No ____
If
t
he an
s
wer
t
o any of
t
he preced
i
ng que
sti
on
s
is
“Ye
s
,”
st
a
t
e on a
s
epara
t
e
s
hee
t
of paper
t
he
na
t
ure of
t
he charge and
i
n wha
t
cour
t
or
j
ur
is
d
i
c
ti
on you were charged
/
conv
i
c
t
ed. You
m
ay be
requ
i
red
t
o ob
t
a
i
n and prov
i
de
t
o
t
he Ok
l
aho
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a
St
a
t
e Depar
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en
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ti
on off
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c
i
a
l
cer
ti
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i
ed
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e
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of a
ll
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and
/
or po
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ce record
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a
t
e and na
ti
ona
l
(f
i
ngerpr
i
n
t
-ba
s
ed) fe
l
ony background check
s
on any
app
li
can
t
. If a background check
is
requ
i
red,
it
w
ill
be a
t
t
he app
li
can
t
s
expen
s
e.
C
and
i
da
t
e’
s
Na
m
e
:
_______________________________________
C
and
i
da
t
e’
s
Si
gna
t
ure
:
____________________________________
Da
t
e
:
_________________________________________________
January 2021
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