"Criminal History Form - Telemarketing Registration Statement" - Delaware

This "Criminal History Form - Telemarketing Registration Statement" is a document issued by the Delaware Department of Justice specifically for Delaware residents with its latest version released on June 25, 2002.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Delaware Department of Justice.

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Download "Criminal History Form - Telemarketing Registration Statement" - Delaware

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State of Delaware
Department of Justice
Telemarketing Registration Statement
CRIMINAL HISTORY FORM
(Page One of Two)
Instructions. If the Registrant indicated yes under Section III, this form must be completed for
each conviction, guilty plea, or current prosecution.
Information Pertaining to the Person Subject to the Conviction, Guilty Plea, or Current
Prosecution:
Name
Address Line # 1
Address Line # 2
City, State, Zip
Person’s Relationship with the Registrant
(Please Circle All that Apply)
1-Registrant 2-Owner 3-Telemarketer 4-Manager 5-Director
Nature of the Action
(Please Circle)
1-Racketeering
2-Violation of State Securities Laws
3-Violation of Federal Security Laws
4-Theft
5-Fraud
6-Forgery
7-Other Offense Involving Falsehood Or Deception (Please Indicate Offense): ___________
Status of Action
(Please Circle)
1-Conviction
2-Guilty Plea
3-Current Prosecution
The name and address of the court having jurisdiction in this matter:
Court’s Name
Address Line # 1
Address Line # 2
City, State, Zip
State of Delaware
Department of Justice
Telemarketing Registration Statement
CRIMINAL HISTORY FORM
(Page One of Two)
Instructions. If the Registrant indicated yes under Section III, this form must be completed for
each conviction, guilty plea, or current prosecution.
Information Pertaining to the Person Subject to the Conviction, Guilty Plea, or Current
Prosecution:
Name
Address Line # 1
Address Line # 2
City, State, Zip
Person’s Relationship with the Registrant
(Please Circle All that Apply)
1-Registrant 2-Owner 3-Telemarketer 4-Manager 5-Director
Nature of the Action
(Please Circle)
1-Racketeering
2-Violation of State Securities Laws
3-Violation of Federal Security Laws
4-Theft
5-Fraud
6-Forgery
7-Other Offense Involving Falsehood Or Deception (Please Indicate Offense): ___________
Status of Action
(Please Circle)
1-Conviction
2-Guilty Plea
3-Current Prosecution
The name and address of the court having jurisdiction in this matter:
Court’s Name
Address Line # 1
Address Line # 2
City, State, Zip
State of Delaware
Department of Justice
Telemarketing Registration Statement
CRIMINAL HISTORY FORM
(Page Two of Two)
The name and address of any governmental agency, prosecutor’s office, probation office,
or law enforcement agency involved in the matter:
Agency’s Name
Address Line # 1
Address Line # 2
City, State, Zip
Agency’s Name
Address Line # 1
Address Line # 2
City, State, Zip
Agency’s Name
Address Line # 1
Address Line # 2
City, State, Zip
The case, docket or identification numbers as used by the court having jurisdiction over the
matter:
The extent the Registrant is on probation, owes any restitution, fines, penalties or
assessments to any person or governmental authority because of this matter:
Revised 6/25/02
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