Affirmation of No Criminal History

If you have no criminal history, complete this form to officially affirm your status in our records. NOTE: This only needs to be completed if you currently have a new or renewal application on file with Occupational Licensing.

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.

/ /

ATTESTATION of NO CRIMINAL HISTORY

Check this box to attest that you have no record of convictions, pending charges, or arrests.

Attestation

By checking this box I attest that I have not been arrested or received a criminal conviction.

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.