For Official Use Only DCP-CHRO Rev 3/16 STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Telephone: (860) 713-6100 Email: dcp.licenseservices@ct.gov Web Site: www.ct.gov/dcp REVIEW OF CRIMINAL CONVICTION DEAR APPLICANT: Pursuant to Section 46a-80(b) of the Connecticut General Statutes, if your application indicates that you have had a prior felony conviction, the specifics of your felony background must be documented for review in order to determine your eligibility for a license. IF APPLICABLE: 1. Complete the Criminal Conviction Application Worksheet below. 2. Attach copies of your conviction, sentencing, parole and probation documents. 3. Attach a letter from your Probation Officer attesting to compliance with your Probation Order or details regarding noncompliance with your Probation Order. 4. If Probation has been satisfied, attach a letter from your Probation Officer stating when you completed your probationary period. 5. Attach a letter from your Parole Officer attesting to compliance with your Parole Order or details regarding noncompliance with your Parole Order. 6. If Parole has been satisfied, attach a letter from your Parole Officer stating when you completed your parole. If Parole has not been completed, provide the date on which it will be completed. CRIMINAL CONVICTION APPLICATION WORKSHEET Pursuant to CHRO Criteria --SECTION 46a-80 Please Print Clearly APPLICANT:_______________________________________________________________________________________________ DATE OF BIRTH:________________________________SOCIALSECURITY#________________________________________ CHECK ONE: NEW APPLICANT RENEWAL REINSTATEMENT DATE OF APPLICATION__________________ LICENSE TYPE:__________________________________________LICENSE#________________________________________ DATE OF CRIME_________________________________DATE OF CONVICTION____________________________________ SIGNATURE OF APPLICANT:_________________________________________________DATE_________________________ Official Use Only Nature of Crime:_____________________________________________________________________________________________ What is relationship of crime to the license for which the person has applied?_____________________________________________ ___________________________________________________________________________________________________________ What is the degree of rehabilitation?______________________________________________________________________________ What is the time lapsed since conviction or release?__________________________________________________________________ DIVISION DIRECTOR: Approval Denial Refer to Legal Division Refer to Board or Commission Signature__________________________________________________________________Date_____________________________ Instructions for Processing_____________________________________________________________________________________ Additional Information Required_______________________________________________________________________________ THIS FORM IS TO REMAIN WITH LICENSEE'S FILE AS PART OF THE RECORD American LegalNet, Inc. www.FormsWorkFlow.com