LEAD Mentor Application

Lorena ISD

Criminal History Authorization
Pursuant to Texas Education Code Section 22.083, school districts are authorized to obtain a criminal history record on all applicants for employment or volunteers and shall contact the Texas Department of Public Safety to provide the information.

I hereby authorize Lorena Independent School District to conduct investigations inquiries into police records, the state prison system, the Department of Public Safety, and/or any other criminal records to determine my acceptability for employment.

I understand that if I am employed by Lorena Independent School District, I may be discharged from my position if the district obtains information of my conviction of a felony, or any offense involving moral turpitude, that I did not disclose to the District.
Name

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

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

MonthDayYear
Date
Race: (check all that apply)
Gender:
This information will be used only for the purpose of obtaining Criminal History Records. The information will be used solely for employment and will not become part of the applicant's file.
Applicant's Signature:

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Date:

MonthDayYear
Date
Please check one:

EmploymentVolunteerSubstitute

DPS Computerized Criminal History (CCH) Verification

Lorena ISD
I,blanks(applicant 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 information that 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 below) 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 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.
Signature of Applicant

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Date

MonthDayYear
Date
OFFICE USE ONLY:
Agency Name
Lorena 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

Pre-Employment Affidavit for Applicant

For purposes of this affidavit:
Adjudication and conviction refer to a conviction, plea of guilty or no contest (nolo contendre), probation, suspension, or deferred adjudication.

Charge refers to a formal criminal charge as documented by a primary charging instrument (a complaint, information, or indictment) under the Texas Code of Criminal Procedure.

Inappropriate relationship refers to the crime of improper relationship between educator and student in Texas Penal Code section 21.12, and any other inappropriate relationships as determined by the State Board for Educator Certification.
I declare the following:

I have never been charged with, adjudicated for, or convicted of having an inappropriate relationship with a minor.
I have been charged with, adjudicated for, or convicted of having an inappropriate relationship with a minor. The charge, adjudication, or conviction was determined to be false. The following are all the relevant facts pertaining to the charge, adjudication, or conviction:
I have been charged with, adjudicated for, or convicted of having an inappropriate relationship with a minor. The charge, adjudication, or conviction was determined to be true. The following are all the relevant facts pertaining to the charge, adjudication, or conviction.
Declaration of Applicant
The following affidavit is offered to satisfy the requirement of Texas Education Code section 21.009 for a pre-employment affidavit, in accordance with Texas Civil Practices and Remedies Code section 123.001. An applicant who is offered employment will be asked to complete a notarized affidavit attesting to the same.

I declare under penalty of perjury that the foregoing is ture and correct.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Executed inblanksCounty, State of blank, on the Date.
Signature (Signature of Declarant)
I understand that the date of birth I am providing will not be used to determine eligibility for employment but will be used solely for the purpose of this unsworn declaration.
Should be Empty:

Lorena ISD

DPS Computerized Criminal History (CCH) Verification

OFFICE USE ONLY:

Pre-Employment Affidavit for Applicant

Declaration of Applicant