TEXAS DEPARTMENT OF LICENSING AND REGULATION
PO Box 12157 • Austin, Texas 78711 • (512) 463‐6599 • ( 800) 803‐9202 • Fax (512) 475‐2871
DISCIPLINARY ACTION QUESTIONNAIRE
If you have had an occupational license revoked, suspended, probated or denied in any state, county or
municipality, the Department must review your disciplinary action history to determine if you are eligible
to obtain a license. You should provide exact details when completing this form.
Questions regarding this form may be addressed to the TDLR Enforcement Division at (512)539‐5600. Please
mail this form, along with the appropriate application and fee, to the address above. If you need to email it,
please send it to CHQ@tdlr.texas.gov and also provide the type of license you are applying for with TDLR.
Type of License you are applying for: ______________________________
(Ex: Barber, Cosmetologist, Electrician, Towing, etc.)
Name: _________________________________________________Social Security Number: ________________
Last
First
Middle
Address: ___________________________________City: ______________ State: _______ Zip Code: _________
Phone: _____________________________ E‐mail*: _______________________________________________
PART ONE: License Revoked, Suspended or Probated
If you have had one, or more, occupational licenses revoked, suspended or probated, please complete this
section. Please provide the requested information as to each revocation, suspension or probation. Attach
additional pages if necessary.
Type of occupational license:
Full name on the license:
___________
License number:
Date the license was issued: ___________________________________
Name and address of the agency that issued the license:
Name and address of the agency that imposed sanctions, if different from the issuing agency:
Please describe the exact type of sanction received: __________________________________________________
(Example: revocation, suspension, probation, etc.)
Date the sanction was imposed: _______________________________
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Rev 02/2013 DAQ01