* = Required Information
PERSONAL HISTORY STATEMENT
"Texas law gives you the right to know what information is collected about you by means of a form you submit to a state government agency. You can receive and review this information, and request that incorrect information about you be corrected by contacting your licensing representative."
Name
*
Soc. Sec. No.
*
TX. Driver's License No.
*
Date of Birth
*
Mailing Address
*
City
Zip Code
Home Telephone No. (A/C)
*
Name of Operation
Capacity
Your Title or Position at the Operation
Operation Address
City
Operation Address
City
Zip Code
Telephone No. (A/C)
*Indicate if you do not have a Social Security number or a Texas driver's license.
1. EDUCATION:
Elementary or High School (check highest year completed)
1
2
3
4
5
6
7
8
9
10
11
12
Did you graduate or received a GED?
Yes
No
College or University
Name of School
Location City and State
Dates Attended
From
To
Graduated
Yes
No
Type of Diploma or Degree
Major Field of Study
Name of School
Location City and State
Dates Attended
From
To
Graduated
Yes
No
Type of Diploma or Degree
Major Field of Study
Technical Vocational
Name of School
Location City and State
Dates Attended
From
To
Graduated
Yes
No
Type of Diploma or Degree
Major Field of Study
Describe any other special training you have had which you feel is pertinent. Including Continuing Education Units. Give dates, locations, and the name of the organization or agency sponsoring the training.
List any professional licenses, certifications, or credentials you hold.
2. EMPLOYMENT AND EXPERIENCE
- Show all positions held within the last 10 years beginning with current or last employer.
(1)
Dates Employed
From
To
Position
Work Preference
Full Time
Part Time
Employer
Address
(2)
Dates Employed
From
To
Position
Work Preference
Full Time
Part Time
Employer
Address
(3)
Dates Employed
From
To
Position
Work Preference
Full Time
Part Time
Employer
Address
(4)
Dates Employed
From
To
Position
Work Preference
Full Time
Part Time
Employer
Address
Use additional field as necessary
A. Describe the duties of each position listed above that were in the areas of child-care services, child-care personnel supervision, skill-based instruction, recreational or youth development program, and program management or administration.
B. Describe any other experience you have had which you feel is pertinent. Include volunteer work in the description. Give dates and locations.
3. PREVIOUS LICENSES/REGISTRATIONS/LISTINGS
A. Has the Texas Department of Family and Protective Services or any other agency ever registered or listed you to care for children?
Yes
No
If "Yes," when were registered or listed?
From
To
Address
County and State
If you were registered under another name, what was the name?
B. Has the Texas Department of Family and Protective Services or any other agency ever licensed you to care for children?
Yes
No
If "Yes," what kind of license did you have?
When were you licensed?
From
To
Name of operation
Operation Address
County
C. Are you now a foster parent?
Yes
No
D. Have you ever been denied a permit to care for children?
Yes
No
If "Yes," when were you denied?
For what type of child care were you denied?
Operation Address
County
What was the reason for denial?
E. Have you ever had a child-care permit revoked or have you ever been barred/prohibited from operating?
Yes
No
If "Yes," when did the revocation or bar occur?
What was the reason for the revocation or bar?
Operation Address
County
If the revocation or bar occured in another state, list the name and address of the regulatory body that issued the revocation or bar
Indicate the type of child care permit that was revoked or the type of child care you were barred for operating?
F. Has an operation that you owned or operated ever been placed on probation?
Yes
No
If "Yes," when was it placed on probation?
What was the reason on probation?
Operation Address
County
PEOPLE IN THE HOME:
For Child Care Operations in Homes Only:
(Complete only if child care will be provided in the home where the caregiver and family reside.)
The following people 14 years old or older live in my home in addition to myself. Use additional sheets as necessary.
(1)
Name
Age
Date of Birth
Social Security No.
TX. Driver's LIC No.
Relationship
(2)
Name
Age
Date of Birth
Social Security No.
TX. Driver's LIC No.
Relationship
(3)
Name
Age
Date of Birth
Social Security No.
TX. Driver's LIC No.
Relationship
(4)
Name
Age
Date of Birth
Social Security No.
TX. Driver's LIC No.
Relationship
(5)
Name
Age
Date of Birth
Social Security No.
TX. Driver's LIC No.
Relationship
(6)
Name
Age
Date of Birth
Social Security No.
TX. Driver's LIC No.
Relationship
5. HEALTH
A. Are you physically and/or emotionally fit to act as the director/administrator of a child care operation?
Yes
No
If "No," please explain.
B. Is any person listed in #4 physically and/or emotionally impaired?
Yes
No
If "Yes," please explain.
6. CHILD ABUSE/NEGLECT
Have you or has any person listed in Item #4 ever been investigated for abusing or neglecting a child by any of the following agencies?
A. Child Protective Services of the Texas Department of Family and Protective Services
Yes
No
B. County child welfare agency
Yes
No
C. Law enforcement agency (police, sheriff, etc.)
Yes
No
D. Child welfare agency in another state
Yes
No
E. Other (specify)
Yes
No
Please Specify
If "Yes," to any of the above, what was the child's name?
How was the child related?
When did this occur?
Where?
7. CRIMINAL CHARGES/CONVICTIONS
A. Have you or has any person listed in Item #4 ever been convicted of a felony or misdemeanour?
Yes
No
If "Yes," give name of person(s)
Date of Conviction
Location
Give details including type of conviction and disposition:
B. Do you or does any person listed in Item #4 have felony or misdemeanour charges pending with the county or district attorney or is anyone now complying with the terms of a deferred adjudication?
Yes
No
If "Yes," give name of person(s)
Type of Charge
County where charges are pending or length of deferred sentence.
Court No.
Location
Give details
8. FOR DIRECTORS OF LICENSED CENTERS ONLY
Please attach all additional documentation relevant to your education, training, and job experience to this form (e.g: an original DFPS child care director's certificate, college transcripts, original training course certificates, or C.D.A credential). All original documentation will be returned to you after qualification are evaluated.
I certify that this information contains no willful misrepresentation or falsification and that it is true and complete to the best of my knowledge and belief. I hereby authorize the Texas Department of Family and Protective Services to contact the persons listed on this form. I understand that the Department may contact others and, at any time, seek verification of any and all information on this form., I understand that any willful misrepresentation is cause for immediate denial of the application or later revocation of the license.
Signature
Date
Submit