Fillable Missouri Credentialing Board (Missouri Credentialing Board)

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Missouri Credentialing Board (Missouri Credentialing Board)

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Revised 10/14 1
Missouri Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
(573) 616-2303 (FAX) email: help@missouricb.com Jefferson City, MO 65101
Dear Applicant:
Following is the Felony Offense Form that must be filled out and returned with your application for
a MCB credential.
Additional items that should be included with this form are:
1) Verification that you are completely off all court supervision
All materials submitted to the MCB will be considered during your application review. The Board
reserves the right to deny an application based on past felony offenses. However, the Board also
recognizes that people and circumstances do change. Consequently, a history of felony offenses
does not mean that an application will not be approved. The authority to make this decision rests
solely with the Board.
If you have any questions, please feel free to contact the MCB Board office at 573-616-2300.
Sincerely,
Stacey Langendoerfer
Director
Revised 10/14 2
FELONY OFFENSE FORM
NAME: _________________________________________________________________________
Felony arrest(s) and date(s):_________________________________________________________
________________________________________________________________________________
_______________________________________________________________________________
Felony conviction(s) and date(s):_____________________________________________________
________________________________________________________________________________
________________________________________________________________________________
State where Felony arrest/conviction occurred: __________________________________________
For an arrest/conviction in any state other than Missouri, request your criminal
history report from that state to include with this Felony Offense Form.
Sentence(s) received for conviction(s), including any probation or parole: ____________________
________________________________________________________________________________
________________________________________________________________________________
Dates sentence(s) served and date(s) completed: ________________________________________
________________________________________________________________________________
________________________________________________________________________________
Are you presently under court supervision of any kind? ________
(You may not apply for a MCB credential while under court supervision)
Provide details related to your arrest(s)/conviction(s):
________________________________________________________________________________
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Revised 10/14 3
If your felony offense was related to alcohol/drug addiction, please provide information and/or
documentation regarding any purported sobriety or clean time.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Use this space to make any other comment or statement regarding your arrest(s) or conviction(s)
and your life since:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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APPLICANT’S SIGNATURE:
Your signature assures that all of the information that you provided in this form is complete and true and that you
accept the Board’s responsibility and authority to approve or not approve any application for credentialing by the
Board.
_______________________________________________________________________________
Applicant’s Signature Date
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Completed 28 August 2020

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