The application shall be verified and shall include the following:

1. (a) The full name, residence address, telephone number, and date of birth of the employee.
2. (b) The name, address, telephone number, and license number of the employer, and the date the employment commenced.
3. (c) A statement as to whether the employee has been arrested or convicted of a misdemeanor, excluding minor traffic violations.
4. (d) A statement as to whether the employee has been convicted of a felony.