THIS FORM IS NOT TO BB USED AS A CONSENT/ AUTHORIZATION FORM.

Agency to retain this CCH Verification Form for DPS auditing purposes.

    DPS Computerized Criminal History (CCH) Verification Form

    Section 1: Applicant must acknowledge the information in Section 1. Signature & date required.

    Applicant Name (Print):

    I acknowledge that a Computerized Criminal History (CCH) check may be performed by accessing the Texas Department of Public Safety Secure Website and may be based on name and DOB identifiers. Authority for this agency to access an individual's criminal history data may be found in Texas Government Code 411, Subchapter F https://statutes.capitol.texas.gov/.

    Name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history record information (CHRI), therefore the organization conducting the criminal history check is not allowed to discuss with me any CHRI obtained using the name and DOB method.

    Optional Only: If the agency directly requests that I also have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search, I can make an appointment with the Fingerprint Applicant Services of Texas (FAST) by visiting the Crime Records General Information I DPS (texas.gov) Review of Personal Criminal History or call the DPS Program Vendor at 1-888-467-2080, submit a full and complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $25.00 to the fingerprinting services company. Once this process is completed the information on my fingerprint criminal history record may be discussed with me.

    Applicant Signature:

    Date:

    Sign and date to acknowledge the statement above.

    Section 2: Agency use only. Must be completed by authorized personnel conducting search.

    Agency Name:

    Authorized Searcher:

    Signature of Authorized Searcher:

    Date of Search:

    Section 3: Agency use only. Name Based CHRI/CCH Tracking information.

    Purpose for CHRI Search

    Is any part of CHRI stored by agency?

    CHRI Retention Period

    CHRI Storage Method

    CHRI Retention Purpose

    Date CHRI Destroyed

    Destruction Method