Fillable Printable Personal Criminal History Statement
Fillable Printable Personal Criminal History Statement
Personal Criminal History Statement
For assistance or to request this document in an alternate format, please visit //bls.dor.wa.gov/BLS or call 1-800-647-7706.Teletype (TTY) users may use the Washington
Relay Service by calling 711.
BLS-700-324 (3/8/16)
Personal/Criminal History Statement
(For Vehicle and/or Vessel Dealer, Wrecker, Hulk Hauler, Motor Vehicle Salvage Processor,
Scrap Metal Business or Commercial Telephone Solicitor)
Please type or print clearly in dark ink. Complete all spaces or print N/A in spaces that do not apply.
State of Washington
Business Licensing Service
PO Box 9034
Olympia, WA 98507-9034
1-800-451-7985
Type of endorsements(s) you are applying for: (A copy of this form will be provided to the agency that regulates the endorsement.)
Vehicle and/or Vessel Dealer Wrecker/Hulk Hauler/Motor Vehicle Salvage Processor Scrap Metal Business
Commercial Telephone Solicitor
APersonal statement
Business name DBA or trade nameEmail Address
Business location address Street or routeCityCountyState or countryZip code
Check all that apply:
I am a:Sole proprietor Spouse Corporate officer LLC member/manager Manager * Partner
* Manager is needed only if you are applying for a Commercial Telephone Solicitor license
Name LastFirstMiddle
Other names used (maiden, AKA)Social security numberBirthdate mm/dd/yy
Home mailing address Street or route, PO boxCityCountyState or countryZip code
(Area code) Home telephone number(Area code) Work/cell telephone number(Area code) Fax number
BCriminal history
1.Within the last 10 years, have you defaulted or been convicted of or entered a plea of no contest to a gross
misdemeanor or felony crime? (Don't include traffic offenses.) ...................................................................................................
If yes, enter the information requested below and attach additional sheets as needed.
Yes No
Conviction DateChargeCity, county and stateDispositionDocket number
2.Within the last 10 years, have you had any civil court order, verdict, or judgement entered against you?.............................
Yes
No
If yes, enter the information requested below and attach additional sheets as needed.
Conviction DateChargeCity, county and stateDispositionDocket number
CCertification
1.Do you understand that untruthful or misleading answers may be cause for denial of an endorsement and/or
revocation of any endorsement granted?
..............................................................................................................................................
Yes No
2.Do you authorize investigation of your criminal history, financial records and credit history as necessary for
licensing?
............................................................................................................................................................................................................
Yes No
I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.
Signature
X
Date signed
Printed name of person signing abovePlace signed (City, county, state)
UBI number
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