Check One: New Update Date Created/Updated

Texas Department of Public Safety TxDPS Training Education, Management Training System and Research Instructor Biosketch Form Notice: You are providing this information to a state governmental body. You are entitled on request to be informed about the information that a governmental body collects about you (with a few exceptions). You are entitled to receive and review the information, under the provisions of Sec. 552.021 and 552.023 of the Governmental Code. You are entitled to have a state’s governmental body correct information about you that is incorrect, under the provisions of Sec. 559.004 of the Governmental Code. Check One: New Update Date Created/Updated: Personal Information First Name: M.I.: Last Name: Suffix:

Last 4 of SSN.: P.I.D.: Date of Birth:

Home or Contact Address: City: State: Zip Code:

Home or Contact Phone: Cell Phone:

Email: Website:

Contact/Supervisor Name: Contact/Supervisor Phone: Ext:

Qualifications Subjects Taught in Other Schools:

Other Pertinent Information:

Other Miscellaneous Activities:

Other Expertise Qualifications:

Books and Articles Authored:

Related Training:

Education Achieved: Related Certificate:

Law Enforcement Certificates:

Current Employment Agency Name:

Work Address :

City: State: Zip:

Supervisor Name: Supervisor’s Email:

Start Date: Prefix/Rank: Title:

Position: Length of Time in Position:

Duties:

ETR-109 (8/2011) Page 1 of 2 Texas Department of Public Safety TxDPS Training Education, Management Training System and Research

Previous Employment Agency Name:

Work Address :

City: State: Zip:

Start Date: End Date: Prefix/Rank: Title:

Duties:

Agency Name:

Work Address :

City: State: Zip:

Start Date: End Date: Prefix/Rank: Title:

Duties:

Professional Association Association: Title: Effective Date:

Association: Title: Effective Date:

Professional Education/School School: Degree: Degree Date:

School: Degree: Degree Date:

ETR-109 (8/2011) Page 2 of 2