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Criminal History Record Investigation
Please print in ink or type
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NAME: LAST, FIRST, MIDDLE
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Maiden or Other Names Known By |
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Birth Date
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Social Security No. |
Drivers License No. & State
I.D. Card # |
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Highest Level of Education
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School Name |
City, State |
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Ethnicity:
o American
Indian o
Asian o
Black, non-Hispanic
o Hispanic
o White,
non-Hispanic
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Present
Address
City State Zip
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Dates |
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Previous
Address
City State Zip
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Dates |
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Previous
Address
City State Zip
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Dates |
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Previous
Address
City State Zip
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Dates |
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Previous
Address
City State Zip
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Dates |
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Provide addresses for the last 5 years
In
connection with my application for volunteering, I understand that
a complete background investigation regarding criminal record
information may be conducted through an outside agency. (Texas
Education Code Section 21.917) I agree that a Photostat of
this authorization shall be considered as effective and valid as
the original. I authorize and request all law enforcement
agencies to release such information without restriction or
qualification. I also release any agency hired to gather
information from all liability associated with this background
investigation. I have read and understand the above
statement.
_________________________________________- _________________ -
_______________________
Applicant's
Signature Date
Phone Number
Note:
Print, Sign, and Submit this form with your Teacher Education
Program application packet. |
