Arrested in PA for DUI: General Impairment

If the answer to any question is “YES”, attach full details and appropriate supporting documents with a signed and dated personal explanation.

A. HAVE YOU EVER BEEN CONVICTED*OF ANY CRIME, FELONY OR MISDEAMEANOR, AND/OR DO YOU
CURRENTLY HAVE ANY CRIMINAL CHARGES PENDING AND UNRESOLVED, IN ANY COURT?
�� Yes (Attach documents and explanation.) �� No

B. FOR DISCIPLINARY REASONS, HAVE YOU EVER WITHDRAWN AN APPLICATION FOR A LICENSE, HAD AN
APPLICATION FOR A LICENSE DENIED OR REFUSED OR AGREED NOT TO REAPPLY FOR A LICENSE IN
ANY STATE, TERRITORY, POSSESSION OR COUNTRY? A LICENSE INCLUDES A REGISTRATION OR
CERTIFICATION.
�� Yes (Attach documents and explanation.) �� No

C. HAVE YOU EVER HAD A LICENSE SUSPENDED OR REVOKED OR OTHERWISE BEEN THE SUBJECT OF A
DISCIPLINARY ACTION BY ANY LICENSING AUTHORITY IN ANY STATE, TERRITORY, POSSESSION OR
COUNTRY?
�� Yes (Attach documents and explanation.) �� No

* Convicted includes judgment, found guilty by a judge or jury, pleaded guilty or nolo contendere, received probation without verdict, disposition in lieu of trial or ARD.