You must have JavaScript enabled to use this form. East 德州 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. 第一个名字 中间的名字 姓 Driver's License Number: 状态 类: Social Security Number 出生日期 性 -选择-男性女 种族: -无-黑色的拉美裔白色/其它 Address 电子邮件 家庭电话 Address 地址2 城市/城镇 州/省 -选择-阿拉巴马州阿拉斯加美属萨摩亚亚利桑那州阿肯色州Armed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces Pacific加州科罗拉多州康涅狄格特拉华州District of ColumbiaFederate 状态s of Micronesia佛罗里达乔治亚州关岛夏威夷爱达荷州伊利诺斯州印第安纳州爱荷华州堪萨斯肯塔基州路易斯安那州缅因州马歇尔 Islands马里兰麻萨诸塞州密歇根明尼苏达州密西西比州密苏里州蒙大拿内布拉斯加州内华达新汉普郡新泽西新墨西哥纽约北卡罗莱纳北达科他Northern Mariana Islands俄亥俄州俄克拉何马州俄勒冈州帕劳宾西法尼亚波多黎各罗德岛州南卡罗来纳南达科塔州田纳西州德州犹他州佛蒙特州属维尔京群岛维吉尼亚州华盛顿西维吉尼亚州威斯康辛州怀俄明 ZIP/Postal Code 手机 I understand the information I am providing about 年龄, 性, 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. 协议 -选择-我同意我不同意 Consent to Release Data Master of Education Students Only For the purposes of field experiences, 学生 teaching, and/or internship in public schools, I give the Department of Teacher Education at East 德州 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. 我同意