SUPERINTENDENT BOARD OF EDUCATION
Ms. Holly M. Martinez Jeremy Maestas, President
[email protected] Brandon Bustos, Vice President
Website: www.k12espanola.org Katrina Martinez, Secretary
405 Hunter Street Ruben Archuleta, Member
Española, New Mexico 87532 Javin Coriz, Member
505-753-2254 – 367-3303
Fax 505-367-3363 NM HMB
128 Questionnaire
The applicant named below is under consideration for a position in our school district. Per NM
HB 128, the legislature has determined that additional safeguards are necessary in the hiring of
school district employees to ensure the safety of New Mexico' s school children. The individual
whose name appears below has had previous employment with your organization. As a former
employer, we request you provide the information requested on this form within 30 business
days as required by state law ( NM HB 128). Ethical misconduct definitions are found in NM HB
128.
Employee Authorization
Yes, I authorize you to release to the school/ district listed above, all information related
to any acts of ethical misconduct that the school district has substantiated. Such
information includes copies of all related documents, including any rebuttal documents in
personnel, investigative. or other files, in accordance with NM HB 128. I release the
above employer and employees acting on behalf of the employer from any liability for
providing information described in this document.
Employee Name (serves as electronic signature) Employee Email
1. Has the applicant named above ever been Response: No
under an investigation for, or been found to
have violated, any state or federal statute
relating to child abuse or neglect, sexual
misconduct or any sexual offense, including
those offenses prohibited in Chapter 30,
Article 3, 3A, 4, 6, 6A, 9, 37, 37A or 52
NMSA, unless the allegations were false or
unsubstantiated?
2. Has the applicant named above ever been Response: No
under investigation for, or found to have
violated, any ethical rule or policy approved
by a former employer that previously
employed the applicant, unless the allegations
were false or unsubstantiated?
3. Has the applicant named above ever had a Response: No
professional license or certificate denied,
SUPERINTENDENT BOARD OF EDUCATION
Ms. Holly M. Martinez Jeremy Maestas, President
[email protected] Brandon Bustos, Vice President
Website: www.k12espanola.org Katrina Martinez, Secretary
405 Hunter Street Ruben Archuleta, Member
Española, New Mexico 87532 Javin Coriz, Member
505-753-2254 – 367-3303
Fax 505-367-3363 suspended,
surrendered or
revoked due to a finding of child abuse or
ethical misconduct or while allegations of
child abuse or ethical misconduct were
pending or under investigation?
4.Is there any other information you would Response: No
like to disclose that you deem pertinent and
substantive to employment in a position that
includes unsupervised contact with children
or student.
Previous School District, Charter School
Name of School District, or
Charter School or School Name: School Email (not Espanola Public
Schools) *
Eastern Visayas International Montessori School
[email protected] If you are not the right person to complete this request, if could you please
forward this email to the correct person or department, we'd appreciate it, thank
you.
If you have any questions please contact Espanola Public Schools Human
Resources Department at the following email:
[email protected] or 505-367-3317
