Complete a separate Background Statement form for each offense. Date of arrest (approximate if unsure of actual date): ... X0030. Rev. 1/2018 Page 1 o...
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TEXAS STATE BOARD OF PUBLIC ACCOUNTANCY William Treacy, Executive Director (512) 305-7851 FAX (512) 305-7875
333 Guadalupe, Tower 3, Suite 900 Austin, TX 78701-3900 www.tsbpa.texas.gov
Background Statement Name (include all names used) Date of Birth: Month
Day
Year
Social Security Number
On an application filed with the Texas State Board of Public Accountancy, you answered YES to one or both of the following questions. Please provide the additional information required below. If you have already reported details of an arrest or conviction to the Board, you do not have to report them a second time. Have you ever been arrested or charged with a crime by any state or local government or by the federal government? Misdemeanors should be included. You are not required to report criminal records that have been expunged or sealed by an order of the court. You are required to report criminal records subject to a non-disclosure order. Have you ever been convicted or placed on deferred adjudication for a felony or a misdemeanor crime by any state or local government or by the federal government? You are not required to report criminal records that have been expunged or sealed by an order of the court. You are required to report criminal records subject to a non-disclosure order.
Complete a separate Background Statement form for each offense. Date of arrest (approximate if unsure of actual date): Month
Year
City/State where offense occurred Offense(s) Narrative of events leading to the arrest or conviction (please attach additional pages if needed):
TSBPA FORM X0030 Rev. 1/2018 Page 1 of 2
TEXAS STATE BOARD OF PUBLIC ACCOUNTANCY 333 Guadalupe, Tower 3, Suite 900 Austin, TX 78701-3900 www.tsbpa.texas.gov
William Treacy, Executive Director (512) 305-7851 FAX (512) 305-7875
Action taken by the court (disposition) Conviction Dismissed Deferred Adjudication No contest or nolo contendere Probation Refiled Other. If "Other," please describe below the action taken by the court.
Date of court action: Month
Year
Describe court sanctions.
Provide any action you have taken that demonstrates rehabilitation.
Date
Signature of Applicant TSBPA FORM X0030 Rev. 1/2018 Page 2 of 2
