Consent To Perform Background Check Form printable pdf download

ROCKWALL INDEPENDENT SCHOOL DISTRICT

Consent to Perform Background Check

Student Teacher

Confidential

The Rockwall Independent School District is authorized by State law to obtain criminal history record information on

individuals applying for positions in the District (Texas Education Code § 22.083). The information requested below

is necessary to obtain criminal history record information.

Campus

Position

Applicant’s Full Name

(Last)

(First)

(Middle)

Applicant’s Maiden and/or Other Name(s) Used

Applicant’s Address

(Street)

(City)

(State)

(Zip)

(County)

Applicant’s Social Security #

Applicant’s Driver’s License #

Applicant’s Date of Birth

Applicant’s Gender

Applicant’s E-mail Address

Applicant’s Phone #

List two most recent permanent addresses:

(1).

City: _______________________________

County:_______________________________

State: ______________________________

From:

____________

To:

__________

(2).

City: ________________________________

County: ______________________________

State: ______________________________

From:

____________

To:

__________

I have been informed that as a part of this process, the District conducts a background check including but not

limited to a criminal history background check.

I hereby consent to the District’s use of any information secured in performing the background check including but

not limited to a criminal history background check, employment or education verifications, personal reference

check, and/or driving record check.

I have been informed by the District that I have the right to review and challenge any negative information received

that might adversely impact the District’s decision. I have also been advised that the District will give me a

reasonable opportunity to clear up any mistaken information reported.

I understand that the information I am providing about Date of Birth and Gender will be used solely for the purpose

of obtaining criminal history record information.

Applicant Signature ____________________________________

Date______________________________

Parental consent required if applicant under age 18:

Parent Signature ________________________________________

Date ______________________________

Policy DC (LEGAL/LOCAL)

Policies/Procedures

PPR: 10/2010

Consent To Perform Background Check Form

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