The Holland Independent School District is authorized by state law (SB 9) to obtain information and conduct a national criminal history record which includes fingerprints on any individual that will be associated with the children enrolled in our School District. The information requested below is required to obtain a criminal history record. The cost of obtaining the criminal history is the responsibility of the applicant.

Name_________________________________________________________

Last First Middle Maiden

Other names used: ___________________________________________

Social Security number______________________ Date of birth ____________

Drivers License Number ____________________ Issuing State ___________

Sex: ___Male ___Female Ethnicity: ___Black ___White ___Other

I understand that the information I am providing about age, sex, and ethnicity will not be used to determine eligibility for employment but will be used solely for the purpose of obtaining criminal history record information.

______________________________________

Signature Date

This form will be removed from the application and filed separately in the personnel office.