MIME-Version: 1.0 Content-Location: file:///C:/CE889F0D/CriminalHistoryRecordInformationAddendum.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Criminal History Record Information Addendum

Criminal    History    Record    Information    Addendum

 

 

CONFIDENTIAL*

 

The = DEWEYVILLE INDEPENDENT SCHOOL DISTRICT is authorized by law to obtain crimi= nal history record information on applicants the district intends to employ (Te= xas Education Code 22.083).  The information requested below is necessary to obtain criminal history record information.

 

 

Please Print

 

 

NAME &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;  

        =     Last        =             &nb= sp;            =             &nb= sp;           First        =             &nb= sp;            =             &nb= sp;         =     Middle

 

 

 

Social Security Number            =             &nb= sp;            =             &nb= sp;            =       Date of Birth    &nb= sp;            =             &nb= sp;            =             

 

 

Sex:=      Male     Female        =             &nb= sp;      Ethnicity       = Black     White      Other=

 

 

 

I understand that the information I am providing about age, sex and ethnicity will not be used to determine eligibility for employment but will be used solely for the purpose of obtaining criminal history record information.

 

 

 

 

  &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;        

Signature

 

 

  &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;        

Date

 

 

 

 

*This form will be removed from the application a= nd filed separately in the Personnel Office.

12/01/9= 7   TASB Personnel Services 3-4.19