CRIMINAL HISTORY QUESTIONNAIRE INSTRUCTIONS
1.TYPE OF REQUEST – Check the box to indicate whether you are applying for a new license or renewing a license.
2.TYPE OF LICENSE – Provide the type of license you are applying for or renewing. (ex: Barber, Cosmetology, Electrician, Towing, Air Conditioning Technician, etc.)
3.NAME – Write your full legal name in the spaces provided. (Last, First, Middle Name)
4.SOCIAL SECURITY NUMBER (SSN) – Social Security number disclosure is required by Section 231.302(1) of the Texas Family Code in order to obtain a license. Your social security number is subject
to disclosure to an agency authorized to assist in the collection of child support payments. For more information regarding child support payments, contact the Texas Attorney General or call (512)
460-6000 or (800) 252-8014.
5.MAILING ADDRESS – Provide your current mailing address. This is the address where we will send you mail. This address can be a post office box. You can add the zip plus-4 to help the postal service deliver mail more efficiently and accurately.
6.PHONE NUMBER – Provide a telephone number, including the area code, where we can reach you during the day. This may be your office phone number where we can leave a message.
7.DATE OF BIRTH – Provide your birthdate.
8.EMAIL ADDRESS – Provide your email address. TDLR will only use your email address for the purpose of communicating with you electronically in a manner which protects your email address from disclosure under the Public Information Act.
9.COUNTY AND STATE OF CONVICTION OR DEFERRED ADJUDICATION – ex: Travis, TX; Baxter, AR; Fresno, CA.
10.COURT – Give the name of the court your case was held. (ex: 300th District Court, Superior Court, Federal Court)
11.DATE CRIME COMMITTED – Give the date you committed the crime.
12.DATE OF THE CONVICTION OR DEFERRED ADJUDICATION – Give the date you were convicted or received a deferred adjudication.
13.EXACT CRIME YOU WERE CONVICTED OF OR RECEIVED A DEFERRED ADJUDICATION FOR – Give the official description of the offense shown on your court records.
14.WHAT EXACTLY DID YOU DO (CRIME) AND WHY – Give a detailed description of your actions and why you made those decisions, do not simply restate the name of your offense. (If you need more space to write, attach additional sheets)
15.SENTENCE OR ACTION IMPOSED BY THE COURT – (ex: six months in Travis County Jail, deferred adjudication, probation, etc.)
16.RENEWALS – If you are renewing your license, did the conviction or deferred adjudication you described in item 11 occur since your license was last issued? Place a check in the box for No or Yes.
17.PAROLE – If you are not on parole please check No. If you answered Yes list your reporting officer’s name and phone number.
18.PROBATION – If you are not on probation please check No. If you answered Yes list your reporting officer’s name and phone number.
19.DATE AND SIGNATURE OF APPLICANT – Carefully read the statement before signing and dating this criminal history questionnaire.
SEND YOUR COMPLETED APPLICATION AND REQUIRED DOCUMENTS TO:
Texas Department of Licensing and Regulation
P.O. Box 12157
Austin, TX 78711-2157
Documents submitted with your application will not be returned. Keep a copy of your completed application, all attachments, and you check or money order. Do not send cash.
For additional information and questions, please visit the TDLR website. You can request assistance or submit required attachments via TDLR webform or fax (512) 463-9468. You may contact Customer Service Representatives by calling (800) 803-9202 (in state only) or (512) 463-6599; Relay Texas -TDD (800)
735-2989. Customer Service Representatives are available Monday through Friday from 7:00 a.m. until 6:00 p.m. Central Time (excluding holidays).
TDLR Form LIC002 rev November 2020
4. SSN:
CRIMINAL HISTORY QUESTIONNAIRE
TDLR must review your criminal history to determine if you are eligible to receive or renew a license. You must complete this form if you have ever been convicted of a felony or misdemeanor (other than a minor traffic violation) or pleaded guilty or no contest “nolo contendere” (resulting in a deferred adjudication) to any in-state, out of state or federal criminal offense. Provide specific details, attaching a separate questionnaire form for each crime.
Our review may take many weeks or months to complete. Questions regarding this form may be addressed to the TDLR’s Enforcement Division at (512) 539-5600. Please mail this form to the address above, or you may upload this form to our secure site via TDLR webform.
Please note, we will not review this form unless we have received your application or request for Criminal History Evaluation.
1. Type of Request: |
New |
Renewal |
2. Type of License: |
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ex: Barber, Cosmetologist, Electrician, Towing, etc. |
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3.Name:
Last, First, Middle, Suffix (Jr, Sr, III)
(See instruction sheet for disclosure Information)
5.Address:
Number, Street Name, Suite Number/Apartment Number |
City |
State |
Zip Code |
6. Phone No:
(Area Code) Phone Number
8.Email Address:
See instruction sheet for disclosure information
9.County and State of conviction or deferred adjudication:
(ex: Travis, TX)
10.Court:
(ex: 300th Dist. Ct. or Fed. Ct.)
11. Date crime committed:
MONTH/Day/Year
12. Date of conviction or deferred adjudication:
MONTH/Day/Year
13. Exact crime you were convicted of or received a deferred adjudication.
14. Give a detailed description of your actions and why you made those decisions; do not simply restate the name of your offense:
(if you need more space to write, attached additional sheets)
15. Sentence or action imposed by the court: (ex: six months in Travis County Jail)
16. For renewals, did this conviction or deferred adjudication occur since last license was issued: |
No |
Yes |
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17. Are you currently on parole? |
No |
Yes (if yes, list your reporting officer's name and phone number below) |
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Parole Officer’s Name |
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(Area Code) Phone Number |
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18. Are you currently on probation? |
No |
Yes (if yes, list your reporting officer's name and phone number below) |
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Probation Officer’s Name |
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(Area Code) Phone Number |
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19. Date and Signature: |
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By signing below, I affirm I am the applicant completing this form and understand that if I fail to provide full and accurate information, the issuance or renewal of my license could be delayed or denied.
Date Signed |
Signature of Applicant |
TDLR Form ENF001 rev November 2020
