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.)
What was the offense?
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)
I certify under penalty of perjury that the above information is true and correct to the best of my
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/organization personnel file and
send a copy to your LPA.
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/organization, the law requires that you complete
a criminal background check. (Health and Safety Code sections 1522, 1568.09, 1569.17, 1596.871, and 1796.19).
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/organization
has a criminal record exemption. The Department must also tell people who ask, the name of a licensed
facility/organization 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.
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