CRIMINAL HISTORY RECORD FORM

I authorize the Carrollton-Farmers Branch ISD to obtain any criminal history record information relevant to this  request for placement from any pertinent source in accordance with the provisions of the Texas Education Code  Section 22.083, and I further authorize any law enforcement agency, including, but not limited to, any police  department or the Department of Public Safety as well as the Texas Department of Corrections to furnish the  Carrollton-Farmers Branch Independent School District any such record.

___________________________         ____________________________  

                                       Signature                                                       Date

The information below will be used solely for the purpose of obtaining criminal history information. In order to  be considered for placement in a C-FB school, you must complete the information so that a criminal check can  be run.

NAME: ___________________, ___________________, __________________

   LAST                                                         FIRST                                            MIDDLE  

(Your name exactly as it appears on your drivers’ license) 

OTHER NAMES, if any have you worked under or been known by: _______________________________ ___________________________________________________

GENDER: _____Female ____ Male                                          DATE OF BIRTH: ____________________

ETHNICITY: ___American Indian ___ Black ___Asian ___Hispanic ___Other  

DRIVER'S LICENSE NUMBER: _________________________________________________________  

 STATE: ____________________                                                              EXPIRATION DATE: ________