Fillable Request-for-Criminal-History-and-Central-Registry-Check-Form - Background Check Form

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Request-for-Criminal-History-and-Central-Registry-Check-Form - Background Check Form

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The Request-for-Criminal-History-and-Central-Registry-Check-Form - Background Check Form form is 1 page long and contains:

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REQUEST FOR CRIMINAL HISTORY AND CENTRAL REGISTRY CHECK
Complete the following for each person requiring a Criminal History/Central registry Check.
You will also need to attach a copy of your actual driver’s license.
First Name
Middle Name Last Name
First Name (Other Names used)
Middle Name
Last Name
Street Address
City County State Zip code
Telephone Number
Date of Birth Age SSN Male / Female __ Age 14-17 years
__ Age 18 older
List all cities in Texas where there has been residency:
List all states/countries where there has been residency:
Race ___White ___ Asian/Pacific Islander
____Black ___American Indiana/Alaskan Native
Ethnicity (must accompany race)
___Hispanic ___Other
Drivers’ License Number
State in which driver’s license is issued
Please attach a clear scan of your driver’s license/state issued ID in this box:
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Request-for-Criminal-History-and-Central-Registry-Check-Form - Background Check Form

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Completed 15 November 2019

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