LEAD Mentor - Rapoport

CRIMINAL HISTORY RECORD INFORMATION REQUEST

*Confidential*
Rapoport Academy Public School is required by state law to review the criminal history of applicants, employees, student teachers, and 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:
Driver's License Exp. Date:

MonthDayYear
Date
Gender:
Part 1. Ethnicity: Are you Hispanic/Latino? (Choose only one)

Hispanic/Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.Not Hispanic/Latino
Part 2. Race: What is your race? (Choose one or more)

American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains a tribal affiliation or community attachment.Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand and Vietnam.Black or African American - A person having origins in any of the black racial groups of Africa.Native Hawaiian or Other Pacific Islander - A person having origins in any of the original people of Hawaii, Guam, Samoa, or other Pacific Islands.White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
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.
Applicant's Signature:

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Date:

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

DPS Computerized Criminal History (CCH) Verification

Rapoport Academy Public School
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 identifiers 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 conducting the criminal history check for background screening is not allowed to discuss any criminal history record information obtained using the name & 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). I have been made aware that in order to complete this process I must make an appointment with L1 Enrollment Services, submit a full and complete set of my fingerprints, request a copy be sent to the agency listed below, and pay a fee of $24.95 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 in file by your agency. Required for future DPS Audits)
Signature of Applicant

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Date

MonthDayYear
Date
OFFICE USE ONLY:
Agency Name
Rapoport Academy Public School
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 REQUEST

DPS Computerized Criminal History (CCH) Verification

OFFICE USE ONLY: