SECTION IX PERSONAL INQUIRY WAIVER AND VERIFICATION
I understand that the Division of Licensing will conduct any investigation deemed necessary to ensure that
I have met all statutory requirements for licensure. I understand that inquiry shall be made regarding my
criminal history and that subsequent investigation may include my school records, employment history,
person from disclosing to the division any knowledge or information concerning me, and I give permission for
such entity to disclose any information and to provide any record requested concerning me to the division.
The information contained in this application and all attachments I have submitted are true and correct to the
application may be grounds for denial or revocation of the license.
Under penalties of perjury, I declare that I have read the forgoing application and that the facts stated in it are
true.
Signature of Applicant Date Signed
SECTION X EMPLOYER STATEMENT (TO BE COMPLETED BY APPLICANT’S EMPLOYER)
Agency Name:
Agency License #:
Name of Agency Head or Designee (type or print):
Signature: _________________________________________________________
Agency Phone #: _________________________________ Date Signed: ____________________________