Please Print Or Type the Following Information

La Joya Independent School District 200 W. Expressway 83 La Joya, TX 78560 Office (956) 323-2000 ______Campus/Department

RELEASE FORM

I hereby consent to the La Joya Independent School District to make inquiries into my former employment. This permission form may be attached to request information and I hereby authorize the party receiving this form to give full and complete information of any and all records, transcripts, data sheets, service records, letters of recommendation, police records, criminal history records, etc., as may be requested by the La Joya Independent School District. I further acknowledge that the information requested will not become a part of my personnel file if I am employed by the District. I agree that the information will not be disclosed to me but will be treated as confidential by the District, and I waive all rights to see this information.

This information requested below is necessary to obtain criminal history record information as permitted by Texas Education Code Section §22.083. I understand that the age, sex, and ethnic information is required by the Texas Department of Public Safety, and will be used solely for the purpose of obtaining criminal history record information.

Please print or type the following information

Full Name Social Security#

Address

City State Zip Code

Ethnicity Driver’s License# State

Sex: □ Male □ Female Date of Birth Place of Birth

Previous addresses for the past 10 years

Address:

I acknowledge and understand that if I am employed by La Joya I.S.D. before a criminal background inquiry has been completed on me, my employment is conditioned on the results or the inquiry, and that the school district may terminate my employment for any arrest or conviction of a felony or misdemeanor involving moral turpitude (including, but not limited to theft, murder, sexual assault, fraud, and indecency with a minor) which I may have intentionally or negligently failed to disclose to the school district in my application for employment.

Signature Date 10/07/2015 La Joya Independent School District 200 W. Expressway 83 La Joya, TX 78560 Office (956) 323-2000 ______Campus/Department

Doy mi consentimiento al distrito escolar de La Joya para investigar sobre mi empleo anterior. Esta forma sera incluida para obtener informacion necesaria y doy autorizacion a la organizacion que reciba esta forma para que provea toda la informacion de los registros, datos de servicios, cartas de recomendaciones, registro de policia o registro criminal, que sea requerido por el distrito de La Joya. Estoy de acuerdo que esta informacion no sera parte de mi archive personal si es que soy empleado por el distrito de La Joya. Yo estoy de acuerdo de que esta informacion no va a ser divulgada a mi, pero si va a ser tratada confidencialmente por el distrito, y yo renuncio a todos los derechos de ver esta informacion.

La informacion que se le pide en seguida es necesaria para obtener historial criminal de acuerdo al codigo educacional de Tejas, seccion §22.083. Yo entiendo que la edad, sexo y grupo etnico es informacion requerida por el departamento de seguridad publica y es solamente con el proposito de obtener el historial criminal.

Por favor de llenar la informacion enseguida

Nombre Numero Social

Direccion

Ciudad Estado Codigo Postal

Etnicidad Numero de Licencia Estado

Sexo: □ Masculino □ Femenino Fecha de Nacimiento

Lugar de Nacimiento

Direccion anterior por los ultimos diez aňos

Direccion:

Yo reconosco y entiendo que si recibo empleo o participo en el programa de voluntaries antes de que se concluya la investigacion criminal, el distrito escolar de La Joya puede despedirme or informarme que mi servicios no son requeridos debido a que la informacion recibida refleja un historial de convicciones de arrestos, felonias, (incluyido pero no limitado a robo, asalto sexual, asesinato, fraude o indecencia con un menor de edad) que intensionalmente o negligentemente no revelo en su applicacion con el distrito escolar de La Joya.

Firma Fecha

10/07/2015