Fill - Free fillable NEVADA STATE CONTRACTORS BOARD (Nevada State Contractors Board) PDF form

NEVADA STATE CONTRACTORS BOARD

5390 KIETZKE LANE, SUITE 102, RENO, NEVADA, 89511 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150

2310 CORPORATE CIRCLE, SUITE 200, HENDERSON, NEVADA, 89074 (702) 486-1100 FAX (702) 486-1190, INVESTIGATIONS (702) 486-1110

www.nscb.nv.gov

CRIMINAL DISCLOSURE STATEMENT REGARDING CRIMINAL PLEA/CONVICTION

Please complete one form for each plea or conviction, regardless of when the crime was committed or whether it was dismissed or

expunged. All fields must be completed. FAILURE TO REPORT A PLEA/CONVICTION IS CONSIDERED FALSIFICATION

OF THE APPLICATION AND MAY RESULT IN THE DENIAL OF YOUR APPLICATION. Attach all supporting documents

related to this conviction. The Board will not act as your agent in gathering information and supporting documents necessary for

completion of this form.

NAME:_____________________________________________________________________

ARRESTING AGENCY:_______________________________________________________

PLEA/CONVICTION DATE:_____________________ COURT CASE OR DOCKET NUMBER:_____________

COURT NAME & LOCATION:_________________________________________________________________________________

VIOLATION CODE(s):________________________________________________________________________________________

SENTENCE (Describe any punishment imposed by the Court):

____________________________________________________________________________________________________________

INCARCERATION DATE: ____________________________ RELEASE DATE:________________________________

PROBATION/PAROLE DATE:_________________________ RELEASE DATE:________________________________

FINES $________________ PAID? YES NO RESTITUTION $____________ PAID? YES NO

DETAILS OF CRIME (Please provide details of this crime, including a complete description of the facts and circumstances that led to

your conviction. You should include who participated in the crime; who the victim was; what losses were suffered; and when, where,

and how the crime occurred.)

____________________________________________________________________________________________________________

EXPLANATION OF THE CRIME (Please explain why you committed this crime.)

____________________________________________________________________________________________________________

REHABILITATION EFFORTS (What positive changes have you made in your life since this conviction? Please attach

documentation to support any rehabilitation efforts.)

____________________________________________________________________________________________________________

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