Criminal History Record Information

East Texas Baptist University may obtain criminal history record information that relates to a person making application to the Master of Education, Master of Arts in Clinical Mental Health Counseling, and Master of Science in Speech-Language Pathology programs. The information requested below is necessary to obtain criminal history record information.

First Name

Middle Name

Last Name

Driver's License Number

Driver's License State

Driver's License Class

Social Security Number

Birthdate

Sex

Ethnicity

Email Address

Home/Cell Phone

Mailing Address

Country

Street

City

Region

Postal Code

Agreements

I understand the information I am providing about age, sex, and ethnicity will not be used to determine eligibility for admission to the Master of Education and Master of Arts in Counseling programs, but will be used solely for the purpose of obtaining criminal history information.

Consent to Release Data | Master of Education Students Only

For the purposes of field experiences, student teaching, and/or internship in public schools, I give the Department of Teacher Education at East Texas Baptist University authorization to release my name, address, phone number and results from my criminal background check to school districts as a means of placement in public schools only as needed.

I agree