Fillable KEENE INDEPENDENT SCHOOL DISTRICT NOTICE REGARDING CRIMINAL CHECK (Keene Independent School District)

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KEENE INDEPENDENT SCHOOL DISTRICT NOTICE REGARDING CRIMINAL CHECK (Keene Independent School District)

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KEENE INDEPENDENT SCHOOL DISTRICT
NOTICE REGARDING CRIMINAL CHECK
The Keene ISD is authorized by statute to check the background of each applicant for possible
criminal records. I understand this check will be performed based on the information I have
provided.
I certify that all of the personal information I provided is true and correct.
LAST NAME
FIRST NAME
MIDDLE NAME
JR.
SR.
ADDRESS
CITY
STATE
ZIP
BIRTHDATE:
______/_____/________ _________-__________-___________
MONTH DAY YEAR SOCIAL SECURITY NUMBER
___________________________________ ___________________
DRIVER’S LICENSE NO. STATE ISSUED
LIST OTHER NAMES USED, SUCH AS MAIDEN, PREVIOUS MARRIAGES OR NAME CHANGES:
MALE FEMALE
PLEASE LIST ALL THE PLACES OF RESIDENCE BEGINNING WITH 2004
DATES
STATE
________________________________________ ______/_____/________
SIGNATURE DATE
________________________________________________________________________________
FOR OFFICE USE ONLY
Anticipated start date:
Date Check was performed:
SUBSTITUTE
Conditional Clearance
YES NO
VOLUNTEER
Cleared to Work
YES NO
AIDE
INITIAL
TEACHER
OTHER
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KEENE INDEPENDENT SCHOOL DISTRICT NOTICE REGARDING CRIMINAL CHECK (Keene Independent School District)

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Completed 31 July 2021

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