Read CRIMINAL HISTORY RECORD CHECK Form 32.doc text version

CRIMINAL HISTORY RECORD CHECK DATE:_______________

SECTION I 1. ________________________________________________________________ 2. Aliases: __________________________________________ 3. Sex: _________________ (Last, First, Middle) 4. Place of Birth: 5. Ethnic Group: a. City: ____________________________ b. County: _______________________________ c. State or Country: _________________________________ Black: ____ White: _____ Hispanic: _____ Asian: _____ Other: __________ 6. Date of Birth: ________________

7. Social Security Number: _______________________ 8. Drivers License Number: ____________________ State: __________ 9. Home Address: ______________________________________________________________________________________________ (Number, Street, Apartment Number, City, State, Zip Code 10. Check category below, as applicable; ________ A. The person described above is a member of the Texas State Military Forces or an employee of the Adjutant General's Department and requests that in accordance with Section 411.121, Texas Government Code, your agency furnish the information requested in Section III below. ________ B. The person described above is applying for enlistment or appointment in the Texas State Military Forces or employment with the Adjutant General's Department and requests that in accordance with Section 411.121, Texas Government Code, your agency furnish the information requested in Section III below. Printed Name and Rank: _________________________________________ Duty Position: __________________________________________________ Unit: __________________________________________________________ Signature: _____________________________________________________ SECTION II DATA REQUIRED BY PRIVACY ACT OF 1974 AUTHORITY: Title 10, United States Code, Section 504, 505, 510 and 520(a). PRINCIPAL PURPOSE: To determine eligibility, for enlistment/appointment in the Texas State Military Forces or employment by the Adjutant General's Department. ROUTINE USES: This information becomes part of your personnel records, which are used for promotion, reassignment, training and other personnel management actions. DISCLOUSRE: Disclosure is voluntary, however, failure to supply any required information may result in your being refused enlistment/appointment in the Texas State Military Forces or employment by the Adjutant General's Department. The data obtained is for OFFICIAL USE ONLY and will be maintained and used in strict confidence in accordance with applicable law and regulations. Knowingly and willfully making a false statement on this form may be punishable by fine or imprisonment or both. Any information provided by you which might reflect adversely on your past conduct and performance, may have an adverse impact on you in your career in situations such as consideration for special assignment, security clearance, court martial and administrative proceedings, etc. I, ________________________________________________________, a potential enlistee/appointee in the Texas State Military Forces or employee of the Adjutant General's Department do hereby consent to the release of the information requested in Section III. Signature: __________________________________________________ Date:_________________

AGTX-Form 32, 1 June 2003

SECTION III (To be completed by Law Enforcement Agency) 1. Does the individual, described in Section I, have a police or juvenile record, to include minor traffic violations? 2. If yes, please provide a listing of the offense/s or charge/s, the date and the disposition or sentence: Yes ______________ No ______________

3. Is the individual now undergoing court action of any kind? 4. If yes, please provide detail:

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Yes ______________ No _______________

This is to certify that the above data is true and correct according to the records on file in this office. The information is confidential and cannot be used in any other manner except for official purposes. Printed Name & Title: _____________________________________________________________ Agency: ________________________________________________________________________ Signature: _____________________________________________ Date: _____________________

Please Mail to: Headquarters, Texas State Guard Camp Mabry P. O. Box 5218 Austin, Texas 78763-5218

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CRIMINAL HISTORY RECORD CHECK Form 32.doc
APPENDIX ____