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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
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