------------------------------------------------------------------------------------------------------------------------------
_______________________________________________________________________ __________________________________
_______________________________________________________________________ __________________________________
______________________________________________________________________
Pre-Employment Affidavit for Applicant (No Notarization)
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: __________________________________________________________________________.
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.
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.
*
*
This form will be processed separately and not shared with the hiring manager.
Approved by the Texas Commissioner of Education, May 2020.
click to sign
signature
click to edit
![]()
