Applicant Name: Page 3 of 4
Education (An original transcript verifying qualifying degree from an accredited institution must be sent to the
TSBSWE office.) If you are already licensed with the board and your qualifying transcripts are on file, you do not need
to resubmit another copy.
II. Disclosures
1. Have you ever been convicted, pled guilty, or pled no lo contendere to any misdemeanor or felony other than juvenile
offenses or misdemeanor traffic violations?...(includes deferred adjudications) ..............................Yes____ No____
2. Have you ever been found in violation of laws or rules pertaining to professional practice or settled such
charges prior to a formal finding in an administrative proceeding? .......……… ………………….Yes____ No____
3. Have you ever had a judgment against you or settled prior to such a finding in a civil proceeding related
to professional practice? …………………………………………………………………….…….. Yes____ No____
4. Are charges pending against you for any of the above?.................................................................... Yes____ No____
5. Have you had a professional license or certification denied, probated, suspended, or revoked?... Yes____ No____
Please note: Applicants must provide all information relating to criminal history, professional license complaint
history and civil liability suit history. Discovery of any of these past circumstances not disclosed may result in
denial of your license and disclosure of discovered information to other licensing boards.” If you answered YES to
any of the preceding questions, you must attach a detailed explanatory statement. Additional information may be
requested.
6. I have successfully completed the Texas Jurisprudence Exam for Social Workers (JP) and have enclosed the
certificate of completion. ……………………………………………………………………………… Yes____ No____
(You must submit proof of completion of the JP dated within 6 months of the date of your application.)
III. Exam Security Acknowledgments
Initial to indicate that you have read and understood the following statements:
____ I understand that for security purposes I must apply for a license using my legal first middle and last
name, along with applicable suffixes (Sr., Jr., III, etc.).
____ I understand that I must possess an official identification card that identifies me by my legal first middle
and last name, along with applicable suffixes (Sr., Jr., III, etc.).
____ I understand that in order to sit for the examination, I will be required to present a valid photo
identification that identifies me using my legal first middle and last name, along with applicable suffixes
(Sr., Jr., III, etc.) and that the identification of my name must match exactly with my name as listed on
the application.
____ I have attached a copy of my photo identification.
