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.

TxDPS Public Criminal History Search: https://records.txdps.state.tx.us/DpsWebsite/CriminalHistory/

Fingerprint Applicant Services of Texas: http://www.txdps.state.tx.us/administration/crime_records/pages/applicantfingerprintservices.htm

To locate Conviction Docket Numbers, etc., you will need to contact the court in which you were convicted: http://www.courts.state.tx.us/

Type of Application ■

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

New Application
Renewal

BASIC INFORMATION

Last Name

Enter your last name.

First Name

Enter your first name.

Middle Initial

Enter your middle initial.

Other Names

Other names you may go by (nicknames, middle name, etc.)

Suffix

Jr., etc.

Last 4 of SSN

Enter the last 4 digits of your Social Security Number

TCEQ License Number

(If applicable)

Your E-Mail Address

Date of Birth ■

Select your date of birth.

/ /

CONVICTION INFORMATION

Date of Conviction

Date of guilty verdict.

/ /

Offenses

List all offenses of which you were convicted. Include the class and level of charge — for example, "First Degree Felony" or "Class C Misdemeanor."

Docket Number

What is the number of your court proceedings? (If known)

Trial Date

When was your trial?

/ /

Court Where Convicted

For example, "Lee County Court No. 3."

Court Mailing Address

Number and Street or PO Box

City

Mailing Address City

State

ex: TX

ZIP Code

ZIP or ZIP+4

Court Phone Number

(xxx)xxx-xxxx

ARREST INFORMATION

Date Arrested or Charged

Date of arrest or court appearance.

/ /

Pending Charges

If you have any pending charges, enter the name of the county or the court or both here — for example, "Lee County Court No. 3." Include the mailing address and phone number of the county or court office.

Offenses

List all offenses of which you were charged. Include the class and level of charge — for example, "First Degree Felony" or "Class C Misdemeanor."

Docket Number

What is the number of your court proceedings? (If known)

Trial Date

When was your trial?

/ /

Name of Arresting Agency

What law enforcement agency arrested you?

Mailing Address of Arresting Agency

Number and Street or PO Box

City

Mailing Address City

State

ex: TX

ZIP Code

ZIP or ZIP+4

Arresting Agency Phone Number

(xxx)xxx-xxxx

ELECTRONIC SIGNATURE and AFFIRMATION

By entering your name and the last four digits of your Social Security number here, you are signing this form electronically.

Full Name

Enter your full legal name.

Last 4 of SSN

Enter the last 4 digits of your Social Security Number

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.