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<br />Ju~,18, 1002 10:46AM <br /> <br />No,66l! P 4/8 <br /> <br />10. List all convictions for any fclony, crime, or ordinance violation (exclude any <br />traffic ordirmnce violations). (Attach additional pages if necessary) <br /> <br />OFFENSE <br /> <br />DATE <br /> <br />LOCATION <br /> <br />DISPOSTITON <br /> <br />11. Applicant's physical description: <br /> <br />Sex <br /> <br />Hair Color <br /> <br />Eye Color <br /> <br />Height <br /> <br />Weight <br /> <br />Complexion <br /> <br />12. List all training for providing the type of serVices for which this license is <br />requested. Attach copies of all appIOpriale certificates, etc. (Attach additional <br />pages if necessary) <br /> <br />a. <br /> <br />b, <br /> <br />c. <br /> <br />d. <br /> <br />e. <br /> <br />.. <br /> <br />c. <br /> <br />List any other communities in which you !\Ie or have been siroilarly licensed. <br /> <br />a. <br /> <br />b. <br /> <br />c. <br /> <br />d. <br />