This government document is issued by Department of Fair Employment and Housing for use in California
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https://www.google.com/url?client=internal-element-cse&cx=001779225245372747843:baq94yxn95w&q=https://calcivilrights.ca.gov/wp-content/uploads/sites/32/2023/03/Fair-Chance-Act-Sample-Forms-Packet.pdf&sa=U&ved=2ahUKEwimxIu7xsSHAxWeRPEDHYSXNXoQFnoECAkQAQ&usg=AOvVaw2OOvxBY1DfvOM_Gww4uAB_