Fillable PERSONAL HISTORY QUESTIONNAIRE (Department of Motor Vehicles )

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PERSONAL HISTORY QUESTIONNAIRE (Department of Motor Vehicles )

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PERSONAL HISTORY QUESTIONNAIRE
New Update
This questionnaire is filed as part of the licensing application for:
Business License: Principal Registered Agent/Manager
Occupational License: Salesperson Drive School Instructor Traffic Safety School Instructor
Inspector DUI School Instructor
All lines and spaces must be completed in full. If not applicable enter (N/A).
Full Legal Name:
Last First Middle
Additional names you have been known by (maiden name, stage name, nickname):
Mailing Address
Street City State Zip
Physical Address
Street City State Zip
Home Phone Additional Phone
Driver’s License No. State
Date of Birth
Place of Birth
City State
Social Security No. - -
Female
Male
Height
Weight
Hair
Eyes
Scars, marks, and/or tattoos
Employment History for the past 5 years beginning with the most current (without gaps):
From
(month/year)
To
(month/year)
Complete Address/Telephone #
Occupational and Business Licensing
555 Wright Way
Carson City, Nevada 89711 - 0100
(775) 684-4690
www.dmvnv.com
OBL242 (12-2012) Page 2 of 3
Applicant’s Name
Personal History Questionnaire
List names, complete address, and phone numbers of two personal references.
Name
Address
Phone Number
Drive, DUI or Traffic Safety applicants only:
Have you ever been arrested or convicted of a crime or offense, either felony, gross misdemeanor or misdemeanor,
including traffic misdemeanor offenses?
Yes No
All other applicants:
Have you ever been arrested or convicted of a crime or offense, either felony, gross misdemeanor or misdemeanor,
excluding traffic misdemeanor offenses?
Yes No
If “Yes,” list separate charge by date of arrest. Describe the offense, court, and disposition in the appropriate
columns. If additional space required, use a separate sheet of paper.
Date of Arrest
Nature of Offense
Court of Jurisdiction
Disposition of Offense
Are you currently, or have you ever been under supervision of a parole or probation agency of any state? If so, provide
name and address of the agency, name of supervising officer and phone number. Provide a copy of your discharge; if
appropriate (explain.)
Child Support Information:
Nevada Revised Statute 482.319 requires all professional and occupational licensing agencies to request statements
regarding child support from applicants for new licenses and for renewal of all occupational licenses. Please mark the
appropriate response and complete the remainder of the form. Failure to mark one of the three and completion of the
form will result in denial of the application.
I am not subject to a court order for the support of a child.
I am subject to a court order for the support of one or more children and am in compliance with a
plan approved by the district attorney or other public agency enforcing the order for the
repayment of the amount owed pursuant to the order; or
I am subject to a court order for the support of one or more children and am not in compliance
with the order or plan approved by the district attorney or other public agency enforcing the order
for the repayment of the amount owed pursuant to the order.
OBL242 (12-2012) Page 3 of 3
Applicant’s Name
Personal History Questionnaire
Have you previously held or do you presently have a business or occupational license issued by the Department of Motor
Vehicles in this State or by any other State’s occupational licensing authority?
Yes No
If “Yes”, license number State
Have you ever had a business or occupational license, in this state or any other state including a driver’s license, which
was denied, suspended, revoked, or had administrative sanction against it?
Yes No (if Yes, explain)
I hereby authorize the Department of Motor Vehicles to make any background investigation necessary as it pertains to the
issuance of my license. In relation, I authorize any person or entity contacted by the Department of Motor Vehicles, its
agents or employees to furnish any information or opinions they may have during the course of my initial background
investigation. I release from liability and promise to hold harmless under any and all causes of legal action, the State of
Nevada, Department of Motor Vehicles, its agents or employees and all persons or entities furnishing information or
opinions to the Department of Motor Vehicles related to my background investigation. I understand providing false
information or the omission of the requested information in this questionnaire is grounds to deny, suspend, or revoke my
business or occupational license. Furthermore, I understand filing false information to obtain any license or permit is a
criminal act as defined in Nevada Revised Statutes and Nevada Administrative Codes in addition to being subject to the
administrative sanctions as prescribed by law.
________________________________________________________ Date
Signature of Applicant
Signatures must be original. Photocopies are not acceptable.
State of Nevada
County of
Subscribed and sworn before me this day of , 20 by
Notary Public or Authorized Nevada DMV Representative (Notary Seal)
For Department Use Only
Case No
Application completed and signed Fingerprints Background Investigation Total Fees $
Recommendation: Approved Denied
Date
Signature of Employee
Date
Signature of Supervisor (if applicable)
Date
Signature of Investigator (if applicable)
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PERSONAL HISTORY QUESTIONNAIRE (Department of Motor Vehicles )

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Completed 24 December 2020

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