Appendix A
March 2016
To avoid a delay in processing, application must be filled out in its entirety.
Recertification New Applicant
The following information is needed for the TDCJ to conduct a criminal history check to determine whether access to TDCJ units,
facilities, and offices should be approved. Applicants must be (18) years of age to apply. All applicants must have a clear criminal history
for (18) months to be eligible. In addition, if applicable, must have been released from prison for a period of (18) months.
Please be sure to provide ALL of the requested information, if it does not apply please indicate by responding with N/A.
1. Name: 2. Primary Phone#: ( ) -
(Last, First, MI)
Secondary Phone#: ( ) -
3. Mailing Address:
Street City State Zip
Email Address:
(Your email address helps Volunteer Services and staff of the volunteer program you will be serving in to contact you
with information about the status of a program you are involved with at the unit level.)
Emergency Contact:
(Emergency Contact Name/Number)
4. SSN: - - 5. Driver’s License/State ID#: ST
6. Date of Birth: / / 7. Place of Birth: City ST 8. Sex: Female Male
9. Race: White Black Hispanic Amer. Indian Asian or Pacific Island Other
10. Current Employer: Title:
11. Have you ever been employed by the TDCJ? Yes No If yes, give division, department, location, title and dates
of employment:
12. List any offender that you are visiting in unit visitation OR knew prior to their incarceration. Not applicable
Name of Offender: _______________ ID#: Relationship: _____ Facility: ________
13. Are you related to a victim, or a friend of a victim, of any offender or releasee now supervised by TDCJ? Yes No
Name of Offender: ID#: Facility: Relative Friend
14. Are you a victim of, related to, or a friend of any TDCJ offender or releasee now supervised by the TDCJ? Yes No
Name of Offender: ID#: Facility: Victim Relative Friend
(Attach additional pages as needed.)
Please use this section to indicate the program area(s) you are interested in serving. All programs are subject to approval.
Chaplaincy Please provide your Faith Identification/Religious Preference: Place of Worship:
Substance Abuse Treatment Program
Sobriety Date: / / Type of meeting (Please check): AA NA CA WIN Other
Practicum Student Start date: / / Sobriety Date: / /
TTC/Halfway House Sex Offender Treatment Program Parole Division Reentry TCOOMMI
Student Intern Start date: / / Program Area:
Victim Services - NOTE: Volunteers who have a criminal history or who have selected or currently volunteer for offender
programs may be prohibited from volunteering with the Victim Services Division.
Windham School District Unit(s) of interest (includes offices): Other:
*Other may include non-traditional programs, administrative/clerical assistance, or areas not indicated on this form. Please explain.
For Office Use Only
Appendix A
March 2016
To avoid a delay in processing, application must be filled out in its entirety.
For the security and safety of volunteers, offenders, and employees, criminal histories of applicants are reviewed and may require fingerprinting
in some instances. Volunteer applicants with previous felony convictions are not necessarily excluded from participation. All applications will be
reviewed and will receive a response.
Criminal History
When answering the following questions, do not include any violation of the law committed before your 17th birthday if the final decision was made
in juvenile court or under a youth offender law; any conviction record that was expunged under federal or state law; or minor traffic violations.
All other convictions must be included.
1. Have you ever served time in any adult correctional facility? Yes No
If yes, please provide the following:
Years served: State: ID #: Release date: / /
2. Are you currently an active member of a gang? _____________________________________ Yes No
3. Have you ever been a member of a gang? If yes, name and description of gang: _________ Yes No
Beginning date / / ending date: / /
4. Do you have any criminal charges currently pending? Yes No
If yes, please explain:
5. Are you now or have you ever been placed on probation or parole? Yes No
If yes, beginning date / / ending date: / /
*If you are currently on community supervision (parole or probation), a statement from your supervising
officer indicating they are aware that you are applying to volunteer with the TDCJ and that you are
meeting the requirements of your supervision must be submitted to Volunteer Services on original
letterhead, signed and dated (see address below).
6. Have you ever forfeited property/bond as a result of being charged with any criminal act? Yes No
If yes, please explain:
7. Do you have a maiden name, alias, or nickname? If yes, provide: Yes No
8. Have you ever been convicted* of a crime? Felony Misdemeanor Yes No
*Convicted includes deferred adjudication, community supervision and those that may not appear on record at this time, but exc
minor traffic violations. If yes, provide the information below. All convictions apply. Attach additional pages as needed.
When: Where:
Charges: Disposition:
(Result of charge, i.e., community service, paid fine, served time)
Signature _________________________________________________ Date / /
Month Day Year
Submit Application
You are encouraged to complete the application and submit at a TDCJ Volunteer Training session, if there is not a training
session available at this time fax or mail the application as instructed below.
See training schedule for dates and locations
Notice: With few exceptions, you are entitled upon request: (1) to be informed about the information the Texas Department of Criminal Justice (the Agency) collects about you; and
(2) under Texas Government Code §§552.021 and 552.023, to receive and review the collected information. Under Texas Government Code §559.004, you are also entitled to request,
in accordance with the Agency’s procedures, that incorrect information the Agency has collected about you be corrected.