Name:
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Voting Precinct:
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| Home Address: |
| Street: |
City: |
| State: |
Zip: |
| Phone Number: |
Cell Phone Number: |
| Email Address: |
| PURSUANT TO TEXAS GOVERNMENT CODE, SEC. 522.021. I ELECT THAT MY HOME ADDRESS & TELEPHONE NUMBER (CHECK ONE): MAY BE RELEASED / SHALL NOT BE RELEASED TO THE PUBLIC UPON REQUEST UNDER THE TEXAS OPEN RECORDS ACT. FAILURE TO MAKE A DESIGNATION RESULTS IN INFORMATION BEING AVAILABLE FOR PUBLIC ACCESS. |
| In accordance with the law that creates the County Historical Commission, the members of the commission must be individuals who broadly reflect the age, ethnic, and geographic diversity of the county. (Sec 318.003, Texas Local Government Code). |
Age:
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Ethnicity:
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Gender:
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| Additionally, according to the same law, each member must have an interest in historic preservation and an understanding of local history and resources. Please provide any additional information that you would like the court to consider under this item. |
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| Place of Employment: |
| Business Address: |
Telephone:
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Fax Number:
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Professional Background:
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Educational Background:
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| Three (3) personal or proffessional references not related to you: |
Name |
Phone |
Years Known |
Name |
Phone |
Years Known |
Name |
Phone |
Years Known |
Previous volunteer organizations and/or community service:
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| Length of Residency in El Paso County: (Years/Months) |
| Do you have property in El Paso County under your name? (Yes) (No) |
Are your property taxes currently paid? (Yes) (No). If not, please give a brief explanation:
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Are you an elected officer, county employee, county affiliate, or employed as a lobbyist? (Yes) (No)
If so, please specify. |
| Signature: |
Date: |
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BACKGROUND INVESTIGATION AUTHORIZATION FORM
RELEASE OF CONFIDENTIAL INFORMATION
Dear Applicant:
The County of El Paso conducts background investigations on applicants in various departments. This effort is part of the selection process and requires your authorization. By signing this document you acknowledge that you are voluntarily granting permission to the County of El Paso to conduct a background check and you authorize relevant parties to release confidential information. The information will remain confidential and will not be disclosed.
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I,, further hereby authorize the County of El Paso Human Resources Department to obtain all confidential records and information pertaining to a complete background investigation. This may include items such as (but not limited to): personal references, work references, Police Records, Sheriff Records, Driving Record, and any open record request.
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Full Legal Name |
Maiden Name (If Applicable) |
Street Address |
City/State/Zip Code |
Social Security Number |
Driver’s License Number/State |
Date of Birth |
Email |
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List the cities and states in which you have lived in the past 10 years.
|
| 1. |
2. |
| 3. |
4. |
| 5. |
6. |
| Signature of Applicant: |
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