PRS Use Only
|Contractor Name |Contract Number |Telephone No. (A/C) |
|Texas Alliance of Boys & Girls Clubs |24034326 |512-301-7771 |
|Contractor Address (Street, City, ZIP) |Contractor Mailing Address (Street, City & Zip) |County |
|13110 Hwy 290 West Suite 300, Austin, Tx 78737 |13110 Hwy 290 West Suite 300, Austin, Tx 78737 |Travis |
Section 411.114 of the Texas Government Code and agency policy require DFPS to do Criminal and DFPS History Background Checks on Contractors, and on each employee, subcontractor, or volunteer who will be involved in direct delivery services with DFPS clients under a contract and/or access to personal DFPS client information. Identifying information must be provided by Contractors to facilitate this process. Records must be maintained and rechecked every 24 months. Contractors must submit requests for subsequent checks no more than 24 months from the date of the initial request. This information will be used to check for any criminal history and the Department’s records of abuse, neglect and exploitation. It may be necessary for you to obtain additional information if the person does not live in Texas or may have a criminal history in another state. You will be notified of the results of the check.
| |
|I verify (by viewing the person’s social security card and/or driver’s license) that the information on this form contains no willful misrepresentation and that |
|the information given is true and complete to the best of my knowledge. I understand that the Department may contact others and, at any time, seek proof of any |
|information contained here. I understand that any willful misrepresentation or failure to provide identifying information is a cause for denial of the contract or|
|revocation of my contract. |
| |
| |
|____________________________________________ _____________ |
|Signature of Contractor, Owner, Operator, or Authorized Representative Date |
Complete the following for each person requiring a Criminal History/DFPS History Check. All names used currently or in the past by the person must be entered. Verify that the information is accurate by checking the person’s social security card and driver’s license. Retain a copy of this form (along with Form 2970c) for your files., If this request is for a new employee, subcontractor, or volunteer you must submit the request to DFPS AND receive the background check results before the person has direct contact with a DFPS client or DFPS client information.
Please contact your Contract Manager or the Centralized Background Check Unit (pcsbc@dfps.state.tx.us) if you need assistance with completing this form.
|First Name |Middle Name |Last Name |
| | | |
|All other names used (married, maiden, etc) |
|First Name |
| |
|Middle Name |
| |
|Last Name |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
|Social Security Number |Date of Birth |Gender |
| | |M F |
|Street Address |City |State |Zip |
| | | | |
|County |Telephone No. (A/C) |
| | |
|Previous address(es) within the last 5 years: |Relationship of person to requestor |Date Hired |
|Street address |Service Provider | |
| |Volunteer | |
|City/State/Zip |Intern | |
| |Other (describe): | |
| |______________________ | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
|Will this person ever drive DFPS clients? |If yes, Driver’s License # and State of Issuance |
| |N/A |
|Yes No | |
|Ethnicity (must accompany race) |Race |
|Hispanic Non-Hispanic |White Asian/Pacific Islander |
|Unable to Determine |Black American Indian/Alaskan Native |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.