Preliminary Criminal History Evaluation

Case Title

Customer

Subject

Request Form

1. Are you enrolled or planning to enroll in an educator preparation program, OR are you planning to take a certification exam for initial educator certification?

2. Do you have reason to believe that you may be ineligible for educator certification due to a conviction or deferred adjudication for a felony or misdemeanor offense?

Your Email Address

Subject

Your Name (First & Last)

Other Previous Names Used

Date of Birth (MM/DD/YYYY)

Social Security Number (SSN):

Your Phone # (XXX-XXX-XXXX)

Address

City

State

Zip Code

Offense #1

Date of Offense # 1

State and County of Offense #1

Disposition #1

Additional Offense?

NoYes

Offense #2

Date of Offense # 2

State and County of Offense #2

Disposition #2

Additional Offense?

NoYes

Offense #3

Date of Offense # 3

State and County of Offense #3

Disposition #3

Additional Offense?

NoYes

Offense #4

Date of Offense # 4

State and County of Offense #4

Disposition #4

Additional Offense?

NoYes

Offense #5

Date of Offense # 5

State and County of Offense #5

Disposition #5

SECTION D - STATEMENT

Have you ever been investigated by TEA or any other a licensing authority?

Additional Information:

Have you ever had a license, certificate, or permit revoked, denied, suspended, or subject to any other sanction in Texas or any other state?

Additional Information:

Local Reference # (Payment Confirmation)

Note: Confirmation # must be entered in order to submit form.

Name, as shown, on your payment card:

Acknowledge Texas Only

No I consent to the agency obtaining my name-based Texas criminal history information, and I acknowledge that I will not recieve a copy of the criminal history report. I understand that, after I have made payment and submitted the required information for a preliminary criminal history evaluation, TEA staff will send me an evaluation letter by email within 90 calendar days. I acknowledge that the agency’s evaluation will be based solely on my name-based Texas criminal history report and the information that I provide. Therefore, any document or information I do not provide will not be considered reasonably available for the evaluation, but may be considered at the time of my application. Additionally, if I fail to provide the necessary information to TEA within 90 days of payment, TEA may assess a new fee to reactivate my request. I understand that the TEA evaluation letter is the Agency’s opinion about my potential eligibility for educator certification, and there are no appeals to the evaluation.

Acknowledge Non-Exempt

No I acknowledge that my request for a preliminary history evaluation does not exempt me from submitting to a National criminal history check at the time I apply for educator certification. This means I will be required to be fingerprinted and to pay the applicable fees during the application process. Additionally, the agency will review my National criminal history (based on information obtained through the submission of fingerprints), and I may be subject to a investigation based on that criminal history, including any information I failed to submit for this evaluation.

Acknowledge Confidential

No I acknowledge that all documentation received by TEA for the purposes of a preliminary criminal history evaluation becomes the property of TEA and will be destroyed per the Agency’s records retention schedule. I understand that TEA follows the Texas Public Information Act for releasing information. Therefore, information can only be kept confidential to the extent allowed by law.

Acknowledge No Refund

No I understand and agree that the $50 payment is non-refundable. Therefore, once payment has processed, I cannot submit a request for refund of the monies paid to TEA.

Signature

**The signature I provide in this field is treated by TEA like a handwritten signature on a paper form. I confirm that by typing my signature, the information provided is accurate as of today’s date. You will receive a copy of your submission via email.