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Notification of Criminal Charges or Convictions

If you have one or more criminal charges, convictions, or both on your record, complete this form to officially notify us of your status. NOTE: This only needs to be completed if you currently have a new or renewal application on file with Occupational Licensing.

If you have multiple arrests or convictions, you can submit the form as many times as needed to submit all of your information. Alternatively, you can use one of the resources below to acquire your complete criminal history and submit that along with the PDF version of the form, making sure to complete the top portion of the form and signing it.

Type of Application   This form is tied to your application for a license or registration. Is yours a new application or a renewal?

Date of Birth   Please select date of birth
/ /  
Date of Conviction Please select date of conviction
/ /  
Trial Date Please select trial date
/ /  
Date Arrested or Charged Please select date arrested or charged.
/ /  
Trial Date Please select trial date
/ /  
By entering your name and the last four digits of your Social Security number here, you are signing this form electronically.
Affirmation By clicking the Submit button, I affirm that the above information is true and correct. I understand that fraudulent or falsified information could result in denial of this application pursuant to Section 30.33 of the Texas Administrative Code or revocation of my license pursuant to Section 7.303 of the Texas Water Code.