Disciplinary Action Questionnaire - Texas Department Of Licensing And Regulation (Page 2 of 2) in pdf

Disciplinary Action Questionnaire - Texas Department Of Licensing And Regulation Page 2

TEXAS DEPARTMENT OF LICENSING AND REGULATION

PO Box 12157 • Austin, Texas 78711 • (512) 463‐6599 • ( 800) 803‐9202 • Fax (512) 475‐2871

Please state the specific reason(s) for the revocation, suspension or probation:

If suspended or probated, specify the length of time of the suspension or probation:

(Example: 6 months)

What were the terms and conditions of the probation? ______________________________________________

Did you successfully complete the probation?

__Yes __No: If not, why?

PART TWO: License Denied

If you applied for an occupational license and it was denied, please complete this section. If you have

had more than one license denial, please provide the requested information as to each denial. Attach

additional pages if necessary.

Type of occupational license applied for: __________________________________________

Full name on the license: ___________________________________________________________

Date you applied for the license:

Date the license was denied: __________________

Name and address of the agency that denied the license:

Please give the specific reason(s) for the denial:

By signing below, I affirm I am the applicant completing this form and understand that if I fail to

provide full and accurate information, the issuance of my license could be delayed or denied.

______________________________________

_____________________________

Signature:

Date:

* TDLR will only use your email address for the purpose of communicating with you electronically in a manner which protects your email

address from disclosure under the Public Information Act.

Page 2 of 2

Rev 02/2013 DAQ01

Disciplinary Action Questionnaire - Texas Department Of Licensing And Regulation Page 2