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Rent national certification document(s) must accompany this form. Licensee’s Name: License Number: Page 2 of 2 Eligibility Questions - Answering the questions below and signing the form is mandatory 1) [ ] No [ ] Yes *Have you, within the past 24 months or since your last renewal, for any criminal offense, including those pending appeal: A. B. C. D. E. F. G. H. I. J. been convicted of a misdemeanor? been convicted of a felony? pled nolo contendere, no contest, or guilty? received defe.

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