Criminal Background Check
by Wes Mason
January 08, 2010
Motley County Independent School District
Criminal History Information Request
Confidential*
The 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 necessary to obtain criminal history record information.
Please print.
Name_________________________________________________________________ Last First Middle
Social Security Number_____________________ Date of birth_________________________
Driver’s License__________________________________
State and Number
Mailing Address________________________________________________________________
Street City State Zip
Sex: q Male q Female Ethnicity: q Black q White/Other
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.
______________________________________
Signature
______________________________________
Date
