Form C2 Supplemental Legal Reporting

If you have answered “yes” to the legal question involving criminal charges and convictions in your application submitted to the Board for initial licensure, reinstatement, reactivation, or renewal, and you have not previously reported the action for which you answered “yes,” you must also complete and upload this form (C2) which appears as a PDF at the bottom of this page, along with supporting documentation in your possession. If you do not have supporting documentation in your possession, please make all reasonable efforts to contact the jurisdiction where the charge(s) or conviction(s) occurred.

Supporting documents include, but are not limited to:

• A copy of the ticket, judgment of the court, or order of the agency involved.

• A copy of any assessments ordered.

• A copy of any certificates of completion for court ordered service or classes.

You may upload an electronic copy of Form C2 and the above listed documents to the “Additional Information” line item within your application checklist in your Licensee Gateway account. Please direct all additional questions to

Download Form C2 PDF