"Have you ever had a suitability determination made by the Department of Human Resources in connection with a previous criminal history information background check? Yes (__) No (__).
"Have you ever been convicted of a crime? Yes (__) No (__). If yes, state the date, crime, location, punishment imposed, and whether the victim was a child or an elderly or disabled individual.
" ____________________________
" ____________________________
"Date __________ Signature __________________."
Ala. Code § 38-13-4 (1975)