Personal History Disclosure Form Page 2
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4Have you ever been convicted of trafficking in alcoholic beverages, as that offense is def
Have you ever been convicted of the criminal
Have you ever been convicted of obstruction of justice, as that offense is defined in 13 V.S.A. Chapter 67?
Have you ever been convicted of fraud in the o
Have you ever been convicted of alteration of motor vehicle identification numbers, as that offense is defined in 23
V
Have you ever been convicted of perj
If you circled “YES” for any of the offenses listed above, you need to submit the following information for
each offense. Attach additional pages if necessary:
COURT: _____________________________________________________________________
DATE OF CONVICTION: _______________________________________________________
STATUTORY OFFENSE: _______________________________________________________
COURT: _____________________________________________________________________
DATE OF CONVICTION: _______________________________________________________
STATUTORY OFFENSE: _______________________________________________________
COURT: _____________________________________________________________________
DATE OF CONVICTION: _______________________________________________________
STATUTORY OFFENSE: _______________________________________________________
COURT: _____________________________________________________________________
DATE OF CONVICTION: _______________________________________________________
STATUTORY OFFENSE: _______________________________________________________
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Regional Offices – Barre/Essex Jct./Rutland/Springfield/St. Johnsbury
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