BAR/COS - Felony Conviction & Monitoring Information.pdf ...

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Business and Inspections Branch Office of Barber and Cosmetology Licensure

INFORMATION REGARDING FELONY CONVICTION If you have ever been convicted of a felony, pled guilty or nolo contendere to a felony, or accepted a deferred judgment or deferred prosecution to a felony charge, please answer all the questions in this form. If you are currently incarcerated, on parole, probation, or under court supervision, a parole officer, probation officer or an official representative of the court must complete the second page. Upload all relevant documents. 1. Name: _______________________________________________________________________________ Middle Last First Previous Name(s):______________________________________________________________________ 2. Home Address: ________________________________________________________________________ Street & Apt. # City State Zip Code 3. Daytime Telephone: _________________________ E-mail Address: _____________________________ 4. Date of Birth: ______________________ U.S. Social Security Number: ___________________________ 5. Please provide the following for EACH of the reported felonies including ANY felony charges as well as ALL felony convictions: a. Date of Felony Conviction(s): b. Location(s): c. Court(s): d. Felony Charge(s): e. Felony Disposition/ Felony Sentence(s): f. Current Status of Felony Sentence(s): 6. Were there damages or injury to the victim(s)? If so, what type? __________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 7. Did you make any restitution to the victim(s)? _________________________________________________ 8. What have you taken since the crime to become a law-abiding and productive member of society? _______________________________________________________________________________________ 9. Describe in your own words why you deserve the privilege of licensure. ________________________________________________________________________________________ 10. Please list the terms of your Parole or Probation: _____________________________________________ a.

Projected Completion date of Parole/Probation: ______________________________________

I state under penalty of perjury in the second degree, as defined in C.R.S. 18-8-503 that the information contained in this application is true and correct to the best of my knowledge. In accordance with C.R.S. 18-8-501(2)(a)(I), false statements made herein are punishable by law and may constitute violation of the practice act. ______________________________________________________ Applicant Signature

1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800

___________________ Date

F 303.894.0404 www.dora.colorado.gov/professions

INFORMATION FROM COURT OR PROBATION OFFICER If you are currently incarcerated, on parole, probation, or on court supervision as a result of a felony, an independent person must provide the following information in their official capacity as law enforcement personnel, parole/probation officer, or an official representative of the court who has knowledge of the circumstances surrounding the felony conviction(s) reported. 1. Official/Officer: Has the applicant fully disclosed his/her criminal record for Barbering and Cosmetology Licensure above? If not, please provide an in depth explanation of any omissions.______________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

Should you have any questions regarding this information, please contact our Office at (303) 894-7800. _________________________________________ Official’s/Officer’s Name

______________________________________ Official’s/Officer’s Dates assigned to Applicant

_________________________________________ Official’s/Officer’s Title

______________________________________ Official’s/Officer’s Phone Number

_________________________________________ Official’s/Officer’s Address

______________________________________ Official’s/Officer’s E-mail Address

_________________________________________ Official’s/Officer’s City, State, and Zip ATTESTATION I state under penalty of perjury in the second degree, as defined in C.R.S. 18-8-503 that the information contained in this application is true and correct to the best of my knowledge. In accordance with C.R.S. 18-8-501(2)(a)(I), false statements made herein are punishable by law and may constitute violation of the practice act. ______________________________________________________ Applicant Signature

1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800

___________________ Date

F 303.894.0404 www.dora.colorado.gov/professions

MONITORING INFORMATION FROM COURT OR PROBATION/PAROLE OFFICER If you are currently incarcerated, on parole, probation, or on court supervision as a result of a felony, you must sign the release below and submit it to your parole or probation officer, or an official representative of the court who has knowledge of the circumstances surrounding the felony conviction (s) reported. Return the completed form with your application. Court Case Number: ______________________________________________________________________ District Court County Court ____________________________________County, Colorado Charges (verdict or plea of guilty): ________________________________________________________

STATE OF COLORADO For Release of Information to the Division of Professions and Occupations, Department of Regulator Agencies I, __________________________, authorize the exchange of and disclosure of information pertaining to me between the Parole/Probation Department for the State of Colorado, and the boards and programs within the Division of Professions and Occupations, Department of Regulatory Agencies, State of Colorado and its agents thereto. The persons to whom information will be disclosed pursuant to this authorization are: (check all that apply) Boards and Programs within the Division of Professions and Occupations, Department of Regulatory Agencies, State of Colorado. Other: ___________________________________________________________________________ I understand that the requested information will be communicated in writing and used for the following purposes: Provide necessary information to determine my fitness for licensure in a profession or occupation regulated by the receiving entity and to monitor my compliance with the probationary terms as imposed by the sentencing court. Information disclosed will include the following: • •

Status of Supervision Revocation Reports filed with the court (if applicable)

I understand that copies of this form may be used in place of the original. _______________________________________________________ Defendant’s Signature

__________________________ Date

BY THE SUPERVISING PAROLE / PROBATION OFFIC TO BE COMPLETED BY THE SUPERVISING PAROLE/PROBATION OFFICER The status of probation for Defendant, _____________________________________________, is as follows: Compliant as of this date with all terms and conditions of probation and no revocations pending. Non-compliant on this date with terms and conditions of supervision as explained below: Revocation filed, pending hearing is scheduled for: _____________________________________ Probation revoked, sentence pending. Probation revoked, sentence imposed on: ____________________________________________ __________________________________________________________ Probation Officer

1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800

______________________________ Date

F 303.894.0404 www.dora.colorado.gov/professions