Submit a request

Request Form:

Your email address

1. Are you enrolled or planning to enroll in an educator preparation program, OR are you planning to take a certification exam for initial educator certification?

2. Do you have reason to believe that you may be ineligible for educator certification due to a conviction or deferred adjudication for a felony or misdemeanor offense?

Subject

Your Name (First & Last)

Alternate names (maiden, nickname, middle) that may have been used

Date of Birth (MM/DD/YYYY)

Your Phone # (XXX-XXX-XXXX)

Address

City

State

Zip Code

Offense #1

Date of Offense # 1 (MM/DD/YYYY)

State and County of Offense #1

Disposition #1

Additional Offense?

Offense #2

Date of Offense # 2 (MM/DD/YYYY)

State and County of Offense #2

Disposition #2

Additional Offense?

Offense #3

Date of Offense # 3 (MM/DD/YYYY)

State and County of Offense #3

Disposition #3

Additional Offense?

Offense #4

Date of Offense # 4 (MM/DD/YYYY)

State and County of Offense #4

Disposition #4

Additional Offense?

Offense #5

Date of Offense # 5 (MM/DD/YYYY)

State and County of Offense #5

Disposition #5

Description

Local Reference # (Payment Confirmation)

Note: Confirmation # must be entered in order to submit form.

Name, as shown, on your payment card:

Acknowledge Texas Only

Acknowledge Non-Exempt

Acknowledge Confidential

Acknowledge No Refund

Signature

Attachments

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