Authorization
and Consent for
Disclosure of Criminal History Information
In connection with the
evaluation of my suitability for employment, volunteer status or contracted
services to TPWD (either as an independent contractor or as an employee
of an organization or business who has entered into a contract with
TPWD), I give my consent for TPWD to obtain criminal history information
related to my application for employment, volunteer status or contracted
services to TPWD. I understand that criminal history information
includes any criminal conviction records for deferred adjudication,
misdemeanor or felony offenses at age 17 or older. Any such information
will be used solely for employment, volunteer status or contracted services
related considerations and not for any other purpose.
I authorize,
consent, and grant permission to any person or entity to release to
TPWD or its agent(s) any and all information regarding my criminal history.
I waive any and all claims I may have with respect to providing such
information. I understand that TPWD and its agent(s) are not responsible
for the accuracy or completeness of the information contained in such
reports. I release TPWD and its agent(s) from any and all liability,
claims, and lawsuits with respect to the information obtained from any
or all the sources used by TPWD and its agent(s).
I understand
that this authorization is not an offer of employment, volunteer status
or contracted services by TPWD and that any false or misleading information
I have provided to TPWD may result in a refusal to hire, promote, reassign,
or continue employment, volunteer status or contracted services.
I also understand that this authorization is a continuing authorization
and will remain valid until such time as I inform TPWD in writing that
I revoke this authorization.
Please
Legibly Print or Type:
Posting Number:
If
Volunteer, Type of Volunteer:
Position
Title:
State
Park/or Facility Location:
Print
Name:
(Last)
(First)
(Middle)
Address:
(Street)
(City)
(State)
(Zip)
Date of
Birth:
Male Female
(MM / DD / YYYY)
Social
Security Number:
Driver’s
License Number:
(State)
(Number)
Signature of Applicant may be obtained during
interview or any time prior to hire.
Date
Texas Parks and Wildlife Department •
4200 Smith School Road, Austin, Texas 78744 • 1-800-792-1112, press
8 • www.tpwd.state.tx.us/jobs
NOTICE: Texas Parks and
Wildlife Department maintains the information collected through this
form. With few exceptions, you are entitled to be informed about
the information we collect. Under Sections 552.021 and 552.023
of the Texas Government Code, you are also entitled to receive and review
the information. Under Section 559.004, you are also entitled
to have this information corrected.
TPWD
Office Use Only:
Program/Site:
Contact:
PWD 1039 – H0800 (05/09)