LEAD Mentor Application

CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK FOR PROFESSIONAL EMPLOYMENT
Dear Applicant:

Thank you for your interest in HARMONY PUBLIC SCHOOLS. Please complete this criminal background check consent form. Falsifications, misrepresentations, or omissions may disqualify your application. The information supplied will not be given to any other person/company for any purpose.
Position(s) Applied For

Administrator/SupervisorTeacherSubstitute TeacherOther
Other (specify):
APPLICANT INFORMATION
Name

Last NameFirst Name
Middle NameMaiden/other Name
Social Security Number:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Driver's License #:
DL. State:
Date of Birth:

MonthDayYear
Date
Gender:
Ethnicity:
Email Address:
example@example.com
Phone Number (Home)
Please enter a valid phone number.
Phone Number (Cell)
Please enter a valid phone number.
Phone Number (Work)
Please enter a valid phone number.
CERTIFICATION
Do you have a Texas Educator Certificate?

YesNo
Certification Type:

StandardProbationary
Certification Description:
Validity Period:
Starting Date - Ending Date
APPLICANT CERTIFICATE AND RELEASE

(please read carefully and sign below)
I hereby certified that all of the information given herein is complete and accurate to the best of my knowledge. I understand that omission, false, inaccurate or misleading information on this consent form may disqualify my application or dismissal immediatley if discovered after hired.

I agree that by signing this consent form, I authorize Harmony Public Schools and Harmony School of Innovation ("Harmony") to conduct a criminal history background check for purposes of evaluating my fitness for employment. I expressly authorize Harmony to use any information provided during the application process in performing the criminal history check.
Applicant's Signature:

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Date:

MonthDayYear
Date
For efficiency and efficacy this document refers to "Harmony Public Schools." "Harmony Public Schools" is the assumed name of eleven separately chartered open-enrollment charter schools. Each of the campuses is managed by a building principal. As approved by the Texas Education Agency, many of the administrative functions for these schools are carried out by a central administrative office identified as "Harmony Public Schools."

DPS Computerized Criminal History (CCH) Verification

Harmony School of Innovation
I,blanks(applicant, employee name), have been notified that a Computerized Criminal History (CCH) verification check will be performed by accessing the Texas Department of Public Safety Secure Website and will be based on name and DOB identifiers I supply.

Because the name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history, the organization (as listed above) conducting the criminal history check is not allowed to discuss any information obtained using this method, therefore the agency may offer the opportunity to have a fingerprint search performed to clear any misidentification based on the name search, if the search provides a criminal report I know could not be mine.
For the fingerprinting process I will be required to submit a full and complete set of my fingerprints for analysis through the Texas Department of Public Safety AFIS (Automated Fingerprint Identification System). I have been made aware that in order to complete this process I must have the correct fingerprinting (FAST) form from this agency, make an online appointment, submit a full and complete set of fingerprints, and pay a fee of $9.95 to the fingerprinting services company, L1Enrollment Services.
Once this process is completed and the agency receives the data from DPS, the information on my fingerprint criminal history record may be discussed with me.
(This copy must remain on file at Connally ISD. Required for future DPS Audits)
Signature of Applicant

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Date

MonthDayYear
Date
OFFICE USE ONLY:
Agency Name
Harmony School of Innovation
Agency Representative Name
Signature of Agency Representative

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Date

MonthDayYear
Date
Please Check and Initial each Applicable Space
Purpose of CCH:
Date Printed: Date, Signature
Destroyed Date: Date, Signature
Retain in your files
Should be Empty:

CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK FOR PROFESSIONAL EMPLOYMENT

APPLICANT INFORMATION

CERTIFICATION

APPLICANT CERTIFICATE AND RELEASE

DPS Computerized Criminal History (CCH) Verification

OFFICE USE ONLY: