Other First Names: Other Middle Names: Other Last Names: Street Address: City: State: Zip Code: County: Telephone Number: Date of Birth: Gender: ( ) - Male Female List any other city in Texas where the person has been a resident, and any addresses, including county, where the person has lived outside of Texas in the previous five years: Ethnicity (must accompany race): Race: Hispanic White American Indian/Alaskan Native Non-Hispanic Black Native Hawaiian/ Pacific Islander Asian Social Security Number: Will this person ever drive DFPS Photo ID Type: clients? Driver License: Yes No Number: State: If yes, their driver license number State ID: and state of issuance must be submitted. Initial Check 24 Month Fingerprint Check Required Person has previously Check completed an FBI check through DFPS or TEA In addition to obtaining a DPS name-based criminal history check, fingerprint-based criminal history checks are required for any PCS contractor and individuals on their staff who, at the time of his or her initial background check request: • currently lives or has lived outside of Texas within the past five years; or • currently lives or has lived outside of Texas in the 24 months since his or her last fingerprint-based criminal history check was completed. If the individual requires a fingerprint-based criminal history check, you must select one of the following choices and provide either an email address or phone number for the person. This information will be required when the person schedules a fingerprint appointment. Preferred method of contact for scheduling fingerprint appointment: Email: Telephone Number: ( ) - Relationship of person to contractor: Date Hired: Applicant for employment Contractor Applicant to Volunteer Staff Other (describe): Volunteer
Other First Names: Other Middle Names: Other Last Names: Street Address: City: State: Zip Code: County: Telephone Number: ( ) - Date of Birth: Gender: Male Female List any other city in Texas where the person has been a resident, and any addresses, including county, where the person has lived outside of Texas in the previous five years: Ethnicity (must accompany race): Hispanic Non-Hispanic Race: White Black Asian American Indian/Alaskan Native Native Hawaiian/ Pacific Islander Social Security Number: Photo ID Type: Driver License: Number: State: State ID: Will this person ever drive DFPS clients? Yes No If yes, their driver license number and state of issuance must be submitted. Initial Check 24 Month Check Fingerprint Check Required Person has previously completed an FBI check through DFPS or TEA In addition to obtaining a DPS name-based criminal history check, fingerprint-based criminal history checks are required for any PCS contractor and individuals on their staff who, at the time of his or her initial background check request: • currently lives or has lived outside of Texas within the past five years; or • currently lives or has lived outside of Texas in the 24 months since his or her last fingerprint-based criminal history check was completed. If the individual requires a fingerprint-based criminal history check, you must select one of the following choices and provide either an email address or phone number for the person. This information will be required when the person schedules a fingerprint appointment. Preferred method of contact for scheduling fingerprint appointment: Email: Telephone Number: ( ) - Relationship of person to contractor: Contractor Staff Volunteer Applicant for employment Applicant to Volunteer Other (describe): Date Hired:
Pkg4-FormE-2971c-Request-Criminal-History.docx