TEXAS STATE BOARD OF PLUMBING EXAMINERS

929 E 41ST ST, AUSTIN, TEXAS 78751 ▪ 512-936-5200 ▪ tsbpe.texas.gov

SUPPLEMENTAL CRIMINAL HISTORY INFORMATION FORM

USE THIS FORM ONLY IF YOU HAVE PAST CRIMINAL CONVICTIONS AND HAVE

OBTAINED AN ELECTRONIC FINGERPRINT BACKGROUND REPORT

►

READ pages ALL THREE PAGES of this form BEFORE completing this form. ►Do not leave

any spaces blank. ►Send this form, along with all required attachments (as listed on page 2 and 3).

along with proof of your previously submitted exam, renewal or registration application if completed

online. ►Your application will not be scheduled for review until you provide all information, attachments

and have signed page 3 of this form. Instead, it will remain in pending status until completed or it

expires. ►Expired applications require re-submittal with a new fee.

Applicant Name (Last) (First) (Middle)

Date Email Address

Age Date of Birth Day Phone # Soc. Sec. #

Address City State Zip

What are you applying for? (check one or more):

New registration Examination Renewal - license or registration #

Complete all three columns below by listing all felonies that you have been convicted of in this or any other state

or country. Also include all felony probation/parole violations. ALL CONVICTION INFORMATION MUST BE

LISTED BELOW AND CONTINUED ON ADDITIONAL PAGE, IF NECESSARY.

Date of Conviction: Offense Convicted of: Disposition (resulting sentence, fine, etc.):

If you have more than 4 convictions and/or probation or parole violations, you must attach an additional sheet

to continue list of conviction dates, offenses, probation/parole violations and dispositions.

Are you currently incarcerated? Yes No

If “Yes”, expected date of release:

Have you ever been incarcerated? Yes No If “Yes”, date of last release:

Are you presently on probation or parole? Yes No Which one?

Projected date of completion of probation or parole:

10.

Probation or Parole Officer’s Information - Name

Email address: Phone No.

City County State

TEXAS STATE BOARD OF PLUMBING EXAMINERS

929 E 41ST ST, AUSTIN, TEXAS 78751 ▪ 512-936-5200 ▪ tsbpe.texas.gov

PAGE TWO – TSBPE - SUPPLEMENTAL CRIMINAL INFORMATION HISTORY FORM WITH

ELECTRONIC FINGERPRINT BACKGROUND REPORT SUBMITTAL

11.

YOU MUST explain in detail what you did (to whom, why, when and where) to cause you to be arrested for the

crimes of which you were convicted and the reasons for any probation/parole violations. YOU MUST ATTACH

ADDITIONAL SHEETS IF NECESSARY TO PROVIDE A FULL EXPLANATION.

► Your goal is to demonstrate that you are rehabilitated, so put your best effort into completing these

steps and attaching all documents. Below is a checklist of all information that is required in order for your

application to be reviewed. Only when you complete each item on this checklist and send all attachments will

your application be scheduled for review.

► If you submit incomplete or partially completed forms or attachments, your application will not be

scheduled for review. Instead, it will be placed in pending status until complete or it expires. You will not be

contacted and asked to submit information that you failed to submit. If your application expires, you will be

required to re-submit a new application, an additional fee and all required information.

Checklist: Check off ✓ each item as you complete it and submit all items together (in one

envelope) to the Board for review and consideration of your application.

Attach complete registration, examination or renewal application and fee, or complete an online

application and send proof of the online payment.

Complete this Supplemental Criminal History Information Form (no items left blank). You must list all

felony convictions and probation/parole violations under item 5, and explain each conviction and

probation/parole violation under item 11 (attach additional pages if needed).

If you have a conviction for a sexual offense, you must obtain and provide to the Board the written

results of a recently performed standard, nationally recognized test and evaluation by a licensed

professional therapist or counselor who is certified as a Registered Sex Offender Treatment Provider in

the State of Texas, to determine the level of likelihood to commit future crimes of a sexual nature.

If you are currently on probation or parole you must submit a current letter, signed and dated from your

probation or parole officer stating that you are in compliance with the terms and conditions of your

probation or parole. The letter must be on official letterhead. Page 3 provides for the release of this

information to the TSBPE.

TEXAS STATE BOARD OF PLUMBING EXAMINERS

929 E 41ST ST, AUSTIN, TEXAS 78751 ▪ 512-936-5200 ▪ tsbpe.texas.gov

PAGE THREE – TSBPE - SUPPLEMENTAL CRIMINAL INFORMATION HISTORY FORM

WITHELECTRONIC FINGERPRINT BACKGROUND REPORT SUBMITTAL.

Attach signed and dated letters on official letterhead from your current and past employer(s).

The letter(s) must provide the following information:

A. that the employer is aware of all your criminal conviction(s)

B. why the employer believes you are now rehabilitated

C. that the employer believes you are not a threat to the public’s health, safety and welfare.

The letter(s) from the past or present employers must be signed and dated by the Responsible

Master Plumber(s) if you are/were employed by a plumbing company.

Submit other letters of recommendation and proof of rehabilitation to be considered. Examples

would be certificates of successful completion of rehabilitation classes, courses or programs and

signed letters of recommendation from anyone who can attest to your rehabilitation. You may

submit as many letters as you wish. All letters must be signed and dated and must have a

telephone number to contact the person for verification.

Sign and date this form below, only after you have read, understand and attest to the following

statements:

“I, THE APPLICANT, UNDERSTAND THAT ANY FALSE INFORMATION ENTERED ON THIS FORM

OR INCLUDED IN ANY ATTACHMENTS COULD RESULT IN DENIAL OR REVOCATION OF MY

REGISTRATION(S) OR LICENSE(S) AND THE ISSUANCE OF ADMINISTRATIVE AND CRIMINAL

PENALTIES.

IN ADDITION, I AUTHORIZE THE TEXAS STATE BOARD OF PLUMBING EXAMINERS TO VERIFY

AND OBTAIN INFORMATION PERTAINING TO MY CONVICTION(S) FROM LAW ENFORCEMENT,

CORRECTIONAL OFFICERS, PRESENT AND PAST EMPLOYERS, SEXUAL ASSAULT

PROGRAMS, OR ANYONE SPECIFICALLY NOTED ON THIS APPLICATION AND ANY OTHER

PERSONS. BY MY SIGNATURE BELOW I HEREBY AFFIRM THAT ALL OF THE FACTS,

STATEMENTS, AND ANSWERS CONTAINED HEREIN AND ALL ATTACHMENTS ARE TRUE AND

CORRECT.”

Signature of Applicant Date Signed

PAGE 3 OF 3

SCHIF WITH FINGERPRINT REPORT FORM Edited November 2017