YISD

Human Resources Division
Personnel Department
Criminal Background Consent

Dear Intern:
It is necessary to obtain the information contained by the Computerized Criminal History database maintained by the Texas Department of Public Safety. This data is requested of all individuals interested in working with students, as a volunteer, employee, or intern with the Ysleta Independent School District. This action is pursuant to the Texas Education Code Section 22.083. Thank you for your cooperation.

All fields marked with an * MUST be filled out

First Name: *
Middle Initial:
Last Name: *
Address: *
City: *
State: *
Zip Code: *
Primary Phone Number: *
Secondary Phone Number:
Primary E-mail Address: *
Secondary E-mail Address:
Teacher preparation college/university:
Other college/university:
 
Please select to indicate assignment:
*
 
Other Assignment:  
       
Are you a current YISD employee?
If YES, List Campus/Department:  
If YES, What is your Job Title:  
     
Have you ever been convicted of, pled guilty or no contest (nolo contendre) to, or received probation, suspension, deferred adjudication or pre-trial diversion for a felony or offense involving moral turpitude (including, but not limited to, theft, rape, murder, swindling, and indecency with a minor)?  
If YES, please explain:
 
At least one row of the next section, MUST be filled out.
Campus Assigned
(Name of school) 		Area of Certification
(EC 4, 4-8 Gen, Science...) 		Assignment
(grade level or content area assigned) 		Name of Teacher
Assigned
 
Social Security Number: (No dashes) *
Driver License or ID Number:   *
 
Maiden Name (if applicable)

I, , an applicant/volunteer/intern working with students for employment, volunteer, or internship work with the Ysleta Independent School District, do hereby authorize the District to obtain any criminal history information that relates to me. This authority is given pursuant to Section 22.083 of the Texas Education Code. I also agree to notify YISD within 24 hours should my criminal record change in any way. Failure to do so on my part may result in dismissal as an employee, volunteer or student intern.
 
Date of Birth(MM/DD/YYYY): *
 
Gender: *
 
Today's Date: 9/2/2010

Type "YES" if you agree to the above: *