LEAD Mentor Application

West Independent School District

Criminal History Record Information Request
The West 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 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
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Sex:
Ethnicity:
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
Should be Empty:

West Independent School District