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Legal background
Answer the following
Answer the questions below. If you answer “Yes,” attach a detailed explanation.
1. Within the last 5 years, in this state or any other jurisdiction, have you had any action
(ne, suspension, revocation, censure, surrender, etc.) taken against any professional or
occupational license, certication, or permit held by you? ........................... Yes No
2. Within the last 5 years, in this state or any other jurisdiction, have you defaulted, or been
convicted of, or entered a plea of no contest to a gross misdemeanor or felony crime?
(Don’t include trac convictions.).............................................. Yes No
By completing this application, you authorize any business associates (past and present) and any
government agencies (local, state or federal) to release any information, les, or records which may be
required for a background investigation to the Department of Licensing.
I declare under penalty of perjury under the law of Washington that the foregoing is true and correct.
TYPE or PRINT Name
Date and place Applicant signature
Providing any false information in this application may be cause for denial, suspension, or revocation
of your professional license in the State of Washington.
PSG-690-010 (R/1/23)WA
When you have completed this form, please print it out and sign here.