HLS 0037 2/06 Page 1 of 2
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FOR INSTRUCTIONAL USE ONLY ***************************
READ BEFORE COMPLETING YOUR DMA FORM
Forms not conforming to the specifications listed below or not submitted to the appropriate agency or office will
not be processed.
To complete this form, you will need a copy of the Terrorist Exclusion List for reference. The Terrorist Exclusion List
can be found on the Ohio Homeland Security Web site at the following address:
http://www.homelandsecurity.ohio.gov/dma.asp
Be sure you have the correct DMA form. If you are applying for a state issued license, permit, certification or
registration, the “State Issued License” DMA form must be completed (HLS 0036). If you are applying for employment
with a government entity, the “Public Employment” DMA form must be completed (HLS 0037). If you are obtaining a
contract to conduct business with or receive funding from a government entity, the “Government Business and
Funding Contracts” DMA form must be completed (HLS 0038). The Pre-certification form (HLS 0035) should only be
completed if you are specifically instructed to do so by the agency or office requesting the form.
Your DMA form is to be submitted to the issuing agency or entity. “Issuing agency or entity” means the government
agency or office that has requested the form from you or the government agency or office to which you are applying
for a license, employment or a business contract. For example, if you are seeking a business contract with the Ohio
Department of Commerce’s Division of Financial Institutions, then the form needs to be submitted to the Department
of Commerce’s Division of Financial Institutions. Do NOT send the form to the Ohio Department of Public Safety
UNLESS you are seeking a license from or employment or business contract with one of its eight divisions listed
below.
Department of Public Safety Divisions:
Administration
Ohio Bureau of Motor Vehicles
Ohio Emergency Management Agency
Ohio Emergency Medical Services
Ohio Homeland Security*
Ohio Investigative Unit
Ohio Criminal Justice Services
Ohio State Highway Patrol
* DO NOT SEND THE FORM TO OHIO HOMELAND SECURITY UNLESS OTHERWISE DIRECTED. FORMS SENT
TO THE WRONG AGENCY OR ENTITY WILL NOT BE PROCESSED.
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FOR INSTRUCTIONAL USE ONLY ***************************
HLS 0037 2/06 Page 2 of 2
Ohio Department of Public Safety
DIVISION OF HOMELAND SECURITY
http://www.homelandsecurity.ohio.gov
PUBLIC EMPLOYMENT
In accordance with section 2909.34 of the Ohio Revised Code
DECLARATION REGARDING MATERIAL ASSISTANCE/NO ASSISTANCE TO A TERRORIST ORGANIZATION
This form serves as a declaration of the provision of material assistance to a terrorist organization or organization that supports
terrorism as identified by the U.S. Department of State Terrorist Exclusion List (see the Ohio Homeland Security Division Web site for
the Terrorist Exclusion List).
Any answer of “yes” to any question, or the failure to answer “no” to any question on this declaration shall serve as a disclosure that
material assistance to an organization identified on the U.S. Department of State Terrorist Exclusion List has been provided. Failure to
disclose the provision of material assistance to such an organization or knowingly making false statements regarding material
assistance to such an organization is a felony of the fifth degree.
For the purposes of this declaration, “material support or resources” means currency, payment instruments, other financial securities,
funds, transfer of funds, and financial services that are in excess of one hundred dollars, as well as communications, lodging, training,
safe houses, false documentation or identification, communications equipment, facilities, weapons, lethal substances, explosives,
personnel, transportation, and other physical assets, except medicine or religious materials.
LAST NAME FIRST NAME MIDDLE INITIAL
HOME ADDRESS
CITY STATE ZIP COUNTY
HOME PHONE
( )
WORK PHONE
( )
DECLARATION
In accordance with section 2909.32 (A)(2)(b) of the Ohio Revised Code
For each question, indicate either “yes,” or “no” in the space provided. Responses must be truthful to the best of your knowledge.
1. Are you a member of an organization on the U.S. Department of State Terrorist Exclusion List?
Yes No
2. Have you used any position of prominence you have with any country to persuade others to support an organization
on the U.S. Department of State Terrorist Exclusion List?
Yes No
3. Have you knowingly solicited funds or other things of value for an organization on the U.S. Department of State
Terrorist Exclusion List?
Yes No
4. Have you solicited any individual for membership in an organization on the U.S. Department of State Terrorist
Exclusion List?
Yes No
5. Have you committed an act that you know, or reasonably should have known, affords "material support or resources"
to an organization on the U.S. Department of State Terrorist Exclusion List?
Yes No
6. Have you hired or compensated a person you knew to be a member of an organization on the U.S. Department of
State Terrorist Exclusion List, or a person you knew to be engaged in planning, assisting, or carrying out an act of
terrorism?
Yes No
In the event of a denial of licensure due to a positive indication that material assistance has been provided to a terrorist organization, or
an organization that supports terrorism as identified by the U.S. Department of State Terrorist Exclusion List, a review of the denial may
be requested. The request must be sent to the Ohio Department of Public Safety’s Division of Homeland Security. The request forms
and instructions for filing can be found on the Ohio Homeland Security Division Web site.
CERTIFICATION
I hereby certify that the answers I have made to all of the questions on this declaration are true to the best of my knowledge.
I understand that if this declaration is not completed in its entirety, it will not be processed and I will be automatically
disqualified. I understand that I am responsible for the correctness of this declaration. I understand that failure to disclose
the provision of material assistance to an organization identified on the U.S. Department of State Terrorist Exclusion List, or
knowingly making false statements regarding material assistance to such an organization is a felony of the fifth degree. I
understand that any answer of “yes” to any question, or the failure to answer “no” to any question on this declaration shall
serve as a disclosure that material assistance to an organization identified on the U.S. Department of State Terrorist
Exclusion List has been provided by myself or my organization. If I am signing this on behalf of a company, business or
organization, I hereby acknowledge that I have the authority to make this certification on behalf of the company, business or
organization referenced above.
X
APPLICANT SIGNATURE DATE
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