LEAD Mentor Application

Robinson Independent School District

Background Study
The District obtains criminal history record information on anyone having access to students under authority of Texas Education Code Section 22.083. The information requested on this form is necessary to obtain that information from any pertinent source and any state or national law enforcement agency, including without limitation the Texas Department of Corrections, and will be used only for the purpose of seeking criminal history information.

To the extent permitted by law, Robinson ISD, will maintain the confidentiality of your criminal history record.
Name

Last NameFirst Name
Middle Name
Driver's License #:
DL. State:
Date of Birth:

MonthDayYear
Date
Ethnicity:
Organization You Are Representing:
Contact Person at Robinson:
Applicant's Signature:

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Date:

MonthDayYear
Date

DPS Computerized Criminal History (CCH) Verification

Robinson 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).
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 by your agency. Required for future DPS Audits)
Signature of Applicant

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Date

MonthDayYear
Date
OFFICE USE ONLY:
Agency Name
Robinson 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

Robinson ISD Pre-Employment Affidavit for Applicant Offered Employment
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 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.
The following affidavit is offered to satisfy the requirement of Texas Education Code section 21.009 for a pre-employment affidavit.

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)
Before me blanks (insert the name of the notary), on this day personally appeared blank (insert the name of the applicant), known to me (or proved to me on the oath of Type a label or through Type a label (description of identity card or other document) to be the person whose name is subscribed to the foregoing instrument) and acknowledged to me that he executed the same for the purpose and consideration therein expressed. Given under my hand and seal of office
Date
(Personalized Seal)
Notary Public's Signature

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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.

*This form will be processed separately and not shared with the hiring manager.
Should be Empty:

Robinson Independent School District

DPS Computerized Criminal History (CCH) Verification

OFFICE USE ONLY:

Robinson ISD Pre-Employment Affidavit for Applicant Offered Employment