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“Texas law gives you Ihe

You can receive and review thisrighi toknow what Infon{ is collected about you by mean
Incorrect infonnatlon about you of a form you submit to aiThovemment agency.
information, and request.....I s
be corrected by contactingS. .Aic
enslng-representat
AFFIDAVIT FOR APPLICANT
S FOR EMPLOYMENT WI
CHILD-CARE FACILITY OR TH A
RFH
AN APPLICANT FOR TEM
PO
child-placing agency or reg RARY OR PERMANENT EMPLOYMENT with a license
iste d child-care facility, lice
agency, or home involves dir red child-cam home whose employment or potential em nsed
ect inte raction with or the opportuni ployment with the facility
execute and submit the
following affidavit with the app ty to int era ct and associate with childr ,
lication for employment: en must
STATE OF 7Z A9-V
COUNTYOF
swear or affirm under pen
as a juvenlle alty of perjury that I do not
now and 1 have not at any tim
e, either as an adult or
1. 9eenconvlctedof
2. Pleaded guilty to (whether or
3. Pleaded nob conteridere riot resulting in a conviction);
4. or no contest to
Admitted
5. Had any judgment or order ren
6. Entered into any settlement dered against me (whether by default or otherwise);
7. of
Had any license, certificatio an action or dairn o1
8. ResIgned under threat of tem n, employment, or volunteer pos
ition suspended, revoked, term
9. Had a report of child abuse ilnatlon of employment orvolunteerism for; inated, or adversely affected
because of
or
10. Have any pending criminal chaneglect made and substantiated against me for; or
rges against me In this or any
other JurisdictIon for;
Any conduct, matter, or thi
ng (Irrespective of formal nam
under criminal or civil law of e thereof) constituting or
any jurisdiction): involving (whether
I. Any felony
2. Rape or other sexual assault;
3. PhysIcal, sexual, emotional abu
4. se andfor neglect of a minor;
Incest
5. Exploitation, Including sexual,
8. Sexual misconduct with a min of a minor;
7. MolestatIon of a child; or;
8. Lewdness or Indecent exposu
9. Lewd and lascMoua behavio re;
10. Obscene or pornographic liter;
11. Assaud, battery, or any vio rature, photographs, or videos;
is. lent offense involving a minor;
Ertdangermentofachfld
13. Any misdemeanor or other offe
14. Unfitness as a parent or cus nse classification involving a minor or to which a minor was
tod
15. Removing children from a stat ian; a witness;
18. Restrictions or limitations on e or concealing children In violation of a court order;
abuse, neglect, or exploitatio contact or visitation with children or minors resulting from a
court order protecting a child or
17. Any type of child abduction. n; or, minor from

Except the following (list all

incidents, locations, descri
ption, and date) (11 none, wr
--
ite NONE)

The failure or refusal of the

applica nt to sign or provide the affidav

bk4c //
it constitu tes good cause for refusal to
hire the applicant.
Signed:
Date: 72ftØJ7
Subscribed and sworn to or affi
rmed) before me this
day of
Signature of notary officer:_
_____________________
(seal, if any, of notarial officer) _____________________
__________

My commission expires:

Form 2985 I 3-04