You must have JavaScript enabled to use this form. East Texas Baptist University may obtain criminal history record information that relates to a person making application to the Master of Education and Master of Arts in Clinical Mental Health Counseling programs. The information requested below is necessary to obtain criminal history record information. First name Middle Name Last name Driver's License Number: State Class: Social Security Number Date of Birth Sex - Select -malefemale Ethnicity: - None -BlackHispanicWhite/Other Address Email Home Phone Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Cell phone 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. Agreement - Select -I agreeI disagree 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
