Get TX DARS3910 2011-2024

2. Mail this form and the fee to DARS DHHS PO Box 12306 Austin TX 78711 3. Allow 30 days for processing. DARS3910 06/11 Page 1 of 2 Code of Professional Conduct Tenets 1. Division for Rehabilitation Services Office for Deaf and Hard of Hearing Services Annual Certificate Maintenance DARS DHHS will use the information provided in this form to obtain criminal records. Certificate Holder Information Birth date BEI certification number Certification level Address City Do you have a felony conviction Yes Maiden name State ZIP code County No If yes what is the conviction date Contact Information Daytime phone number Email address Cell phone number optional Video phone number Publish information in DHHS registry Maintenance Method Select one Enclose fee Renewal fee if paid before the expiration date. Fee and Submittal Instructions 1. Enclose a check cashier s check or money order payable to DARS DHHS for the maintenance fee listed above. Interpreters adhere to standards of confidential communication* The full version of the Code of Professional Conduct may be obtained from the DHHS office or the RID Web site at www. rid*org. Signature I attest that all information provided in this application is accurate and true and agree to abide by the Code of Professional Conduct. I understand that my certificate is subject to suspension revocation or cancellation* Date X The application is incomplete without the certificate holder s signature. PO Box 12306 Austin Texas 78711 512 407-3250 Voice or 512 410-1386 VP www. dars. state. tx. us/dhhs/bei. Division for Rehabilitation Services Office for Deaf and Hard of Hearing Services Annual Certificate Maintenance DARS DHHS will use the information provided in this form to obtain criminal records. Certificate Holder Information Birth date BEI certification number Certification level Address City Do you have a felony conviction Yes Maiden name State ZIP code County No If yes what is the conviction date Contact Information Daytime phone number Email address Cell phone number optional Video phone number Publish information in DHHS registry Maintenance Method Select one Enclose fee Renewal fee if paid before the expiration date. Certificate Holder Information Birth date BEI certification number Certification level Address City Do you have a felony conviction Yes Maiden name State ZIP code County No If yes what is the conviction date Contact Information Daytime phone number Email address Cell phone number optional Video phone number Publish information in DHHS registry Maintenance Method Select one Enclose fee Renewal fee if paid before the expiration date. Fee and Submittal Instructions 1. Enclose a check cashier s check or money order payable to DARS DHHS for the maintenance fee listed above. Interpreters adhere to standards of confidential communication* The full version of the Code of Professional Conduct may be obtained from the DHHS office or the RID Web site at www. rid*org. Signature I attest that all information provided in this application is accurate and true and agree to abide by the Code of Professional Conduct. .