Criminal Record Supplemental Form – Fill Out and Use This PDF

STATE OF CALIFORNIA – STATE PERSONNEL BOARD

CRIMINAL RECORD SUPPLEMENTAL QUESTIONNAIRE

(REV. 02/2012)

Not all Examinations require this Criminal Record Supplemental Questionnaire. Please review the Examination Bulletin to determine if the questionnaire is required before completing.

PRINT OR TYPE – PLEASE SEE INSTRUCTIONS ON THE BACK PAGE

Applicant Identification Number (Easy ID)

FIRST 3 LETTERS OF	 MONTH OF BIRTH			DAY OF BIRTH 	LAST 4 DIGITS OF SOCIAL	
LAST NAME AT BIRTH					SECURITY NUMBER
Applicants Name (last)		(First)		(M.I.)	Easy ID
					│
Mailing Address (Number)		(Street)		E-mail Address	Work Telephone Number
				│	│
(City)		(County)	(State)	(Zip Code)	Home Telephone Number
					│

Exam Title(s) for which you are applying:

Answer the following Questions:
1.	Have you ever been convicted by any court of a misdemeanor
	crime of domestic violence?	 YES	 NO
2.	Have you ever been convicted by any court of a felony?	 YES	 NO

Explanations

CERTIFICATION – IMPORTANT – PLEASE READ BEFORE SIGNING – if not signed, your application may be rejected.

I certify under penalty of perjury that the information I have entered on this application is true and complete to the best of my knowledge. I further understand that any false, incomplete, or incorrect statements may result in my disqualification from the examination process or dismissal from employment with the State of California. I authorize all agencies to release any information they may have concerning the information provided on this supplemental application to the State of California.

Applicant’s Signature	Date Signed
	│

STATE OF CALIFORNIA – STATE PERSONNEL BOARD

CRIMINAL RECORD SUPPLEMENTAL QUESTIONNAIRE

(REV. 02/2012)

INSTRUCTIONS

Read the following instructions carefully before completing this Criminal Record Supplemental Questionnaire. If the Examination Bulletin requires this Criminal Record Supplemental Questionnaire to be submitted with your application, you must complete all sections and answer the required questions completely and accurately.

Applicant Identification Number (Easy ID) – Enter the required tracking information on the Criminal Record Supplemental Questionnaire: the first three letters of your last name at birth, the month and day of your birth and the last four digits of your Social Security Number.

Easy ID – The Easy ID represents a compilation of the data collected from the Applicant Identification Number section. If you are unable to determine your Easy ID, please leave it blank.

Exam for which you are applying – Fill in the title(s) of the examination for which you are applying as it is listed on the Examination Bulletin.

Questions 1 & 2 – Answer these questions only if required on the Examination Bulletin.

Explanations – Use this section to explain the details of any response that requires additional information. Be through and attach additional sheet(s) if necessary.

Signature – Your signature and the date signed is required. If the Criminal Record Supplemental Questionnaire is not signed, it may be rejected.

NOTE: Your completed Criminal Record Supplemental Questionnaire and other examination related information submitted to the department administering this examination becomes confidential information and the property of the State of California as provided by Government Code Section 18934. This Application and other confidential information will not be returned; therefore, we recommend that you keep a copy of your completed Application for your personal records. Your rights to inspect your examination papers are set forth in Sections 186-189 of Title 2 of the California Code of Regulations, which can be accessed on the State Personnel Board's website at www.spb.ca.gov.