LEAD Mentor Application

CRIMINAL HISTORY RECORD INFORMATION
La Vegas 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 neccessary to obtain criminal history record information.
Name

Last NameFirst Name
Middle NameMaiden/other Name
Social Security Number:
Date of Birth:

MonthDayYear
Date
Driver's License #:
DL. State:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender:
Ethnicity:
Race: (check all that apply)
I understand 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.
Applicant's Signature:

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Date:

MonthDayYear
Date
This form will be removed from the application and filed separatley in the HR office.

DPS Computerized Criminal History (CCH) Verification

La Vega ISD
I,blanks(applicant or employee name), acknowledge 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. This is not a consent form for that process but serves as information only. This document is to show proof of purpose in performing the CCH search by this organization. Authority of access to an individual's criminal history data may be found in Texas Government Code 411; Subchapter F.
Because the name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history, the organization conducting the criminal history check is not allowed to discuss any criminal history record information obtained using the name and DOB method. Therefore, the agency may request that I have a fingerprint search performed to clear any misidentification based on the result of the name & DOB search.
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). In order to complete this process I must make an appointment with IdentoGo, either online www.identogo.com or by calling 888-467-2080, submit a full and complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $24.95 to the fingerprinting services company.
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 La Vega ISD. Required for future DPS Audits)
Signature of Applicant

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Date

MonthDayYear
Date
OFFICE USE ONLY:
Agency Name
La Vega ISD
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:

CRIMINAL HISTORY RECORD INFORMATION

DPS Computerized Criminal History (CCH) Verification

OFFICE USE ONLY: