CRIMINAL HISTORY INFORMATION REQUEST

CRIMINAL HISTORY INFORMATION REQUEST

Confidential
The White Oak Independent School District is required by Texas Education Code Chapter 22, Subchapter C, to review the criminal history of applicants, employees, independent contractors, student teachers, and certain volunteers. The information requested below is necessary to obtain criminal history record information.¹
Name*

First NameLast Name
Email*
example@example.com
Social Security Number*
Date of Birth*

MonthDayYear
Date
Drivers License State and Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

MaleFemale
Ethnicity*

BlackWhiteHispanicOther
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.¹
Signature (type your full name below)*
Today's Date*

MonthDayYear
Date
¹The information requested is required to complete a name-based criminal history information check with the Texas Department of Public Safety.
Should be Empty: