Pre-Employment Affidavit for Applicant Offered Employment
The following affidavit is offered to satisfy the requirement of Texas Education Code section 21.009 for
a pre-employment affidavit. 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: ___________________________________________________________________________.
I declare under penalty of perjury that the foregoing is true and correct.
(Signature of Declarant) (Date)
______________________________________________________________________
Name
(First, Middle, Last)
______________________________________________________________________
Address
(Street, City, State, Zip Code)
State of Texas
County of _______________
Before me, a notary public, on this day personally appeared _______________, known to me to be the
person whose name is subscribed to the foregoing document and, being by me first duly sworn,
declared that the statements therein contained are true and correct.
(Personalized Seal)
_________________________________
Notary Public’s Signature
Approved by the Texas Commissioner of Education, October 2017.
