A.__Full name;

B.__Full current address and addresses for the prior 5 years;

C.__A record of previous issuances of, refusals to issue and revocations of a license under this chapter; and

D.__Answers to the following questions posed in substantially the following form:

(1)__"Is there a formal charging instrument now pending against you in this or any other jurisdiction for a crime that is punishable by imprisonment for one year or more?";

(2)__"Is there a formal charging instrument now pending against you in this or any other jurisdiction for a juvenile offense that involves conduct that, if committed by an adult, would be punishable by imprisonment for one year or more?";

(3)__"Have you ever been convicted of a crime described in subparagraph (1) or been adjudicated as having committed a juvenile offense as described in subparagraph (2)?";

(4)__"Are you a fugitive from justice?";

(5)__"Are you a drug abuser, drug addict or drug- dependent person?";

(6)__"Have you been dishonorably discharged from the military within the past 5 years?"; and

(7)__"Are you an illegal alien?"

2.__Signature as certification.__The applicant, by affixing the applicant's signature to the application, certifies the following:

A.__That the statements made in the application and any documents made a part of the application are true and correct;