Personal History Disclosure Form

PERSONAL HISTORY DISCLOSURE FORM This form must be completed by individuals who are: (1) Sole proprietors; (2) Officers, directors, partners, or key employees of an applicant; (3) Individuals who own or control the applicant; (4) Officers, directors, and partners of a business concern that owns or controls the applicant; (5) Officers, directors, partners, and key employees of an operator of an off-site facility if the applicant is a government entity. Pursuant to Ohio Revised Code 3734.41 through 3734.47 and Ohio Administrative Code 109:6-1-01 through 109:6-1-04 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS 1. WHO MUST COMPLETE THIS FORM? a. Sole proprietors. b. Each individual who is an officer, director, partner, or key employee of an applicant except for any individual who is an officer, director, partner, or key employee of a Secondary Business Activity Concern. c. Each individual who holds or is able to control, either directly or through a holding company or subsidiary, the purchase or sale of more than five percent of the equity of the applicant, if the applicant is a publicly traded corporation, or twenty-five percent of the equity of the applicant, if the applicant is a privately held business concern. d. Officers, directors, and partners of a business concern that holds or is able to control, either directly or through a holding company or subsidiary, the purchase or sale of at least five percent of the equity of the applicant, if the applicant is a publicly traded corporation, or twenty-five percent of the equity of the applicant, if the applicant is a privately held business concern. e. Officers, directors, partners, and key employees of an operator of an off-site facility for which the applicant is a government entity. As defined by OAC 109:6-1-01(E), "Business concern" means any corporation, association, firm, partnership, trust, sole proprietorship, or other form of commercial organization. File this form with the Applicant Disclosure Form(s) and/or Non-Applicant Business Concern Disclosure Form. 2. FINGERPRINT INSTRUCTIONS. All individuals required to submit a personal history disclosure form must submit fingerprints to the Attorney General. a. Fingerprints may be submitted electronically. An individual who wishes to submit fingerprints electronically may do so by going to any of the vendors identified on the Attorney General's website who are able to take both BCI and FBI fingerprints. The individual must submit electronic fingerprints that will be transmitted by the vendor to both the Ohio BCI and FBI in order to meet his statutory obligations. The Attorney General's website identifying electronic fingerprint vendors is: http://www.ohioattorneygeneral.gov/Services/Business/WebCheck/Webcheck-Community-Listing. * All individuals who provide electronic fingerprints are responsible for ensuring that the results are returned to the Environmental Background Investigation Unit. Processing time may take up to thirty (30) days. Be sure to account for this time when submitting fingerprints electronically. Individuals submitting electronic fingerprints must be sure to list the name and address of the Environmental Background Investigation Unit on the fingerprint form which they provide to the electronic fingerprint vendor. Please list the entity receiving the fingerprint results as: Environmental Background Investigation Unit, 30 E. Broad Street, 25th Floor, Columbus, Ohio, 43215. American LegalNet, Inc. www.FormsWorkFlow.com * * All individuals who provide electronic fingerprints are responsible for paying the electronic fingerprinting fee charged by the vendor. In the event that an individual's fingerprints are not or can not be taken electronically, he or she will be required to submit ink and paper fingerprints. * b. Fingerprints may be submitted by the ink and paper method. Individuals may choose to provide fingerprints by the traditional ink and paper method of fingerprinting. All individuals who choose to provide traditional ink and paper fingerprints must do so on the forms provided by the Attorney General. If an individual resides out-of-state he or she must provide traditional ink and paper fingerprints, unless the Attorney General determines the out-of-state electronic fingerprint vendor he or she proposes to use qualifies to submit electronic fingerprints. 3. HOW SHOULD THIS FORM BE COMPLETED? Read every question carefully before you begin answering any question. Answer every question completely. Do not leave any blank spaces. If a question does not apply, enter "Not Applicable" or "N/A" in the space provided for an answer. If there is nothing to disclose in answer to a particular question, enter "None" in the space provided for an answer. All individuals filing a personal disclosure statement for the first time are required to complete the attached Release Form and submit a complete and readable set of fingerprint cards. 4. ANSWER COMPLETELY AND TRUTHFULLY. Failure to answer any question completely may result in the form being returned for supplementation. If the answer to a question in this form is identical to an answer given to a previous question in the form, you may answer the later question by writing "Same as _____." For example, if the answer to Question 3 is the same as the answer to Question 2, you may answer Question 3 by writing "Same as 2." Failure to submit complete and truthful forms will be taken into consideration in the background investigation. ADDITIONAL SPACE. If you need additional space to answer a question, use plain 8 ½ by 11 paper. Insert additional pages immediately following the page on which the question you are answering appears. Be sure to indicate your answer is "Continued on next page." and indicate on the additional page what question is being answered there. When you have finished answering all questions, and have attached all additional pages, consecutively number each page at the top right corner - including the additional pages. Pages of the original form, which need to be renumbered as a result of adding pages, should be renumbered in the space provided after "Your Page No._____." 6. EXHIBITS. If you are required or wish to submit any document in connection with your answer to any question, refer to it in your answer as "Exhibit No._____" and attach it at the end of the form. TYPE OR PRINT YOUR ANSWERS. Type or print in legible block letter style. 5. 7. 8. INTERPRETIVE ASSISTANCE IN COMPLETING DISCLOSURE