State of New Jersey
DEPARTMENT OF BANKING AND INSURANCE
OFFICE OF ADMINISTRATION AND FINANCE
LICENSING SERVICES BUREAU
PO BOX 473
TRENTON, NJ 08625-0473
TELEPHONE: (609) 292-5340
ARREST AND CONVICTION FORM
Please complete the following questionnaire in entirety.
COMPLETE ANSWERS TO ALL QUESTIONS MUST BE PROVIDED.
Copies of documents pertaining to each arrest, indictment and/or conviction must be submitted.
Further processing of the application cannot occur until all requested information and documents have
been supplied.
1.
Name and seriousness of the crime:
2.
Circumstances under which the crime occurred:
3.
Date(s) of the crime:
4.
Location where crime occurred:
5.
Your age at the time of the crime:
6.
Number of times this same type of crime was committed:
7.
Statement of the social condition which may have contributed to the crime:
8.
Date of indictment, if any (mm/dd/yyyy) :
9.
Date of conviction, if any (mm/dd/yyyy):
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10.
Place of indictment/conviction:
11.
Terms of sentence:
12.
Fines imposed, if any:
13.
Terms of probation, if any:
14
If you have served, or are still on probation, please provide a statement from your probation officer
attesting to the facts of your probation.
15.
Submit any evidence of rehabilitation including, but not limited to, the following:
Evidence of good conduct while in prison, or in the community; evidence of counseling or psychiatric
treatment received; evidence of the acquisition of additional academic or vocation schooling;
evidence of successful participation correctional work-release programs; evidence of
recommendations of persons who have, or have had, you under their supervision; or a
rehabilitation offender’s certificate.
CERTIFICATION
I, the applicant, being duly sworn according to law, depose and say that the information set forth
within this document is true to the best of my knowledge and belief. This information is submitted for
the purpose of satisfying criteria for the issuance of a certificate/license. I understand that any
information withheld, or that represents a material misstatement, will constitute grounds for immediate
rejection of my application by the New Jersey Commission of Banking and Insurance.
PRINT
Complete
Name:
First
MI
SIGN
Complete
Name:
(First, MI, Last)
Date:
mm
dd
Yyyy
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