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Get Candidate Conviction History Questionnaire Form

COUNTY OF LOS ANGELES Candidate Conviction History Questionnaire Position Applying for Exact Title Last Name First Name Middle Initial Other Name s Used Street Address City Apt. Miscellaneous Offenses A. Health Safety Code Section 11357 b or c possession of marijuana or any statutory predecessor to that section where a controlled substance is being used and Section 11550 use of a controlled substance as they relate to marijuana prior to January 1 1976 or any statutory predecessors to those sections CERTIFICATION OF APPLICANT please read carefully I hereby certify that all statements made in this Candidate Conviction History Questionnaire are true and complete to the best of my knowledge. No* State Zip Code Home Telephone Number Alternate Telephone Number - E-mail Address Social Security Number Driver s License Number IMPORTANT You will be asked to submit a copy of this form each time you are being considered for a position* Please retain a copy for your records. CONVICTIONS Have you ever been convicted of any crime by any court including a military court except as provided in the box below YES NO If you responded NO please sign and date the Certification of Applicant below. Certification of Applicant below. The following convictions need not be disclosed Judicially Dismissed Diversion A. Any conviction that was judicially dismissed under Penal Code Section 1203. 4 B. Any record regarding a referral to or participation in any pre-trial or post-trial diversion program currently participating in a deferred entry of judgment program you must disclose that conviction D. A conviction where the Court has ordered the record sealed or dismissed Juvenile Offenses must be disclosed for that particular classification or position regardless of age when convicted* However you must disclose convictions while a juvenile if tried or convicted as an adult* Traffic Offenses A conviction for a traffic offense that was less than 390. I understand that any false incomplete or incorrect statement regardless of when discovered may result in my disqualification or dismissal from employment with the County of Los Angeles. Date Signature of Candidate Page 1 of 2 Please attach additional pages if necessary OFFENSE OR CASE NAME Provide Penal Code or other code section if known DATE on or about c Official Personnel File WHERE VIOLATION OCCURRED City County State SENTENCE STATUS. No* State Zip Code Home Telephone Number Alternate Telephone Number - E-mail Address Social Security Number Driver s License Number IMPORTANT You will be asked to submit a copy of this form each time you are being considered for a position* Please retain a copy for your records. CONVICTIONS Have you ever been convicted of any crime by any court including a military court except as provided in the box below YES NO If you responded NO please sign and date the Certification of Applicant below. CONVICTIONS Have you ever been convicted of any crime by any court including a military court except as provided in the box below YES NO If you responded NO please sign and date the Certification of Applicant below. Certification of Applicant below. The following convictions need not be disclosed Judicially Dismissed Diversion A.

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