Fillable Pre-Employment Affidavit for Applicant Adjudication and conviction refer

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Pre-Employment Affidavit for Applicant Adjudication and conviction refer

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Pre-Employment Affidavit for Applicant
For purposes of this affidavit:
Adjudication and conviction refer to a conviction, plea of guilty or no contest (nolo
contendre), probation, suspension, or deferred adjudication.
Charge refers to a formal criminal charge as documented by a primary charging instrument
(a complaint, information, or indictment) under the Texas Code of Criminal Procedure.
Inappropriate relationship refers to the crime of improper relationship between educator
and student in Texas Penal Code section 21.12, and any other inappropriate relationship as
determined by the State Board for Educator Certification.
I declare the following:
o I have never been charged with, adjudicated for, or convicted of having an inappropriate
relationship with a minor.
o I have been charged with, adjudicated for, or convicted of having an inappropriate
relationship with a minor. The charge, adjudication, or conviction was determined to be
false. The following are all of the relevant facts pertaining to the charge, adjudication, or
conviction: ___________________________________________________________________________.
o I have been charged with, adjudicated for, or convicted of having an inappropriate
relationship with a minor. The charge, adjudication, or conviction was determined to be
true. The following are all of the relevant facts pertaining to the charge, adjudication, or
conviction: __________________________________________________________________________.
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Declaration of Applicant
The following affidavit is offered to satisfy the requirement of Texas Education Code section 21.009 for
a pre-employment affidavit, in accordance with Texas Civil Practices and Remedies Code section
132.001. An applicant who is offered employment will be asked to complete a notarized affidavit
attesting to the same.
I declare under penalty of perjury that the foregoing is true and correct.
_______________________________________________________________________ __________________________________
Name (First, Middle, Last) Date of Birth
_______________________________________________________________________ __________________________________
Address (Street, City, State, Zip Code) County
Executed in ____________________ County, State of ________, on the ________ day of _____________, __________.
County State Date Month Year
_______________________________________________________________________
(Signature of Declarant)
I understand that the date of birth I am providing will not be used to determine eligibility for
employment but will be used solely for the purpose of this unsworn declaration.
*
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This form will be processed separately and not shared with the hiring manager.
Approved by the Texas Commissioner of Education, October 2017.
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Pre-Employment Affidavit for Applicant Adjudication and conviction refer

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Completed 6 July 2021

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