Todays Date: _____/_____/_____ Title: ____________________

First Name: ________________ Last Name: _________________Middle Initial:____ Middle Name: _____________ Social Security Number: ______-_____- _________ Mailing Address: Street_____________________________________________________ City________________ State_______________ Zip___________

Dob : Month: _____ Day:_____ Year:______ Place Birth City:_________________ State:__________________ Drivers License Number: _______________________ State:_________________ Phone Number: (______)–_________________

Other Names Used: (maiden, alias, nicknames): ___________________________________

Sex: Male___ Female: ____

Email Address: ______________________________________

Ethnic Origin: White____ Black____ Hispanic____ Asian/Pac.Islander____Other____ American Indian/Alaskan____

12a. Have you previously been employed by the TDCJ or worked in a TDCJ facility on a contract basis? Yes No
If yes, give unit(s)/department(s), position(s) held, and dates:
12b. Have you engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution?
Yes No
12c. Have you been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or
implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse? Yes No
12d. Have you been civilly or administratively adjudicated to have engaged in sexual activity in the community facilitated by force,
overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse? Yes No
12e. Have you been involved in any substantiated incidents of sexual harassment? Yes No
If yes, please explain:
13. Are you related to any employee or contract employee of the TDCJ? Yes No Unknown
If yes, list name, relationship, and unit/department of assignment:
14a. Are you or any immediate member of your family (to include, but not limited to parent, brother, sister, spouse, or child) related to
a current or former TDCJ offender (incarcerated or on parole)? Yes No Unknown
If yes, provide the name of the offender(s):
14b. Are you now or have you ever been involved in a spousal relationship with a current or former TDCJ offender (incarcerated or on
parole)?
This includes marriage, common-law marriage, lived together, or had a child together. Yes No
If yes, provide the name of the offender(s):
14c. Do you have a current business partnership or gang association with a current or former TDCJ offender (incarcerated or on parole)?
Yes No Unknown If yes, provide the name of the offender(s):
14d. Are you on a current TDCJ offender’s visitation list? Yes No If yes, provide the name of the offender(s):
14e. Have you corresponded in the last year with a current TDCJ offender? Yes No If yes, provide the name of the
offender(s):
NOTE:
If you answered yes to Question 14a, b, c, d, or e above, you are required to complete and submit a PERS 282A, Additional
Offender Information. The PERS 282A form is available from the TDCJ website at www.tdcj.texas.gov.
 If you have a personal relationship with an offender who is not a relative, be sure to read the “Offender Relationships” paragraph on Page
3 of this questionnaire.

15. Do you have any criminal charges currently pending? Yes No
If yes, please explain:
16. Are you on parole or probation, deferred adjudication, or under a pre-trial diversion agreement? Yes No
If yes, please explain:
17. Have you ever been convicted of a crime (misdemeanor or felony)? Yes No If yes, list each one below.
Attach an additional page if necessary. Include those that may not appear on your record at this time.
Important: For purposes of contract employment with the TDCJ, convictions include sentenced to confinement, paid fine, time served,
placed on probation (includes deferred adjudication), and court ordered restitution. See Falsification Policy on Page 3 of this
questionnaire.


18. Are you now or have you ever been a member of a street gang? Yes No
Are you now or have you ever been a member of or affiliated with an organization promoting racial, ethnic, or gender superiority or
separation, independence from governmental laws and regulations, or overthrow of the United States Government?
Yes No
If you answered yes to either of these questions, provide the following information:
a. Name of the organization and dates of membership:
b. Position or positions you held in the organization:
c. Arrests and/or convictions resulting from your activities as a member:
19. Do you have any tattoos or markings on your body signifying membership or affiliation with a street gang or associated with
organizations promoting racial, ethnic, or gender superiority or separation, independence from governmental laws and regulations,
or overthrow of the United States Government? Yes No
If yes, provide a description and location of those tattoos or markings: