<p> 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:</p><p>Last 4 of SSN.: P.I.D.: Date of Birth:</p><p>Home or Contact Address: City: State: Zip Code:</p><p>Home or Contact Phone: Cell Phone:</p><p>Email: Website:</p><p>Contact/Supervisor Name: Contact/Supervisor Phone: Ext:</p><p>Qualifications Subjects Taught in Other Schools:</p><p>Other Pertinent Information:</p><p>Other Miscellaneous Activities:</p><p>Other Expertise Qualifications:</p><p>Books and Articles Authored:</p><p>Related Training:</p><p>Education Achieved: Related Certificate:</p><p>Law Enforcement Certificates:</p><p>Current Employment Agency Name:</p><p>Work Address :</p><p>City: State: Zip:</p><p>Supervisor Name: Supervisor’s Email:</p><p>Start Date: Prefix/Rank: Title:</p><p>Position: Length of Time in Position:</p><p>Duties:</p><p>ETR-109 (8/2011) Page 1 of 2 Texas Department of Public Safety TxDPS Training Education, Management Training System and Research </p><p>Previous Employment Agency Name:</p><p>Work Address :</p><p>City: State: Zip:</p><p>Supervisor Name: Supervisor’s Email:</p><p>Start Date: End Date: Prefix/Rank: Title:</p><p>Position: Length of Time in Position:</p><p>Duties:</p><p>Agency Name:</p><p>Work Address :</p><p>City: State: Zip:</p><p>Supervisor Name: Supervisor’s Email:</p><p>Start Date: End Date: Prefix/Rank: Title:</p><p>Position: Length of Time in Position:</p><p>Duties:</p><p>Professional Association Association: Title: Effective Date:</p><p>Association: Title: Effective Date:</p><p>Association: Title: Effective Date:</p><p>Professional Education/School School: Degree: Degree Date:</p><p>School: Degree: Degree Date:</p><p>School: Degree: Degree Date:</p><p>ETR-109 (8/2011) Page 2 of 2</p>